2023-2028 Texas State
Health Plan

As Required by
Texas Health and Safety Code
Section 104.021-104.026

Statewide Health Coordinating
CouncilNovember 2022
This report was prepared at the direc tion of the Statewide Hea lth
Coordinating Council. The opinions and recommend atio ns
expressed in this report are that of the Council and do not reflect
the views of the Texas Health and Human Service s Commission,
Department of State Hea lth Services, or Texas Health and Hum anServices System

Table of Contents
Table of Contents ................................................................................... 2
1. Executive Summary ........................................................................... 4
2. Background ....................................................................................... 6
3. Access to Care ................................................................................... 7
Defining Access to Care ....................................................................... 7
Populations with Poor Access ................................................................ 9
Texas Populations with Poor Access ................................................. 10
COVID-19 and Access ........................................................................ 13
Nationwide Access ........................................................................ 13
Access in Texas ............................................................................ 14
Race & Ethnicity ........................................................................... 14
Strategies for Improving Access .......................................................... 14
Covering More Texans ................................................................... 15
Provider Participation in Medicaid .................................................... 16
Other Policy Considerations ............................................................ 17
Policy Developments ..................................................................... 17
Policy Recommendations for the Legislature, the Governor, and Executive
Branch Agencies ........................................................................... 18
4. Rural Health .................................................................................... 23
Health Outcomes in Rural Areas .......................................................... 23
COVID-19 ................................................................................... 23
Emergency Medical Services ........................................................... 24
Teleservices................................................................................. 24
Older Adults in Rural Areas ............................................................ 24
Challenges for Low-Income and Uninsured Populations in Rural Areas ... 25
Hospital and Nursing Facility Closures .................................................. 25
Providers ......................................................................................... 26
Older Providers ............................................................................ 27
Obstetric Services......................................................................... 27
Policy Recommendations for the Legislature, the Governor, and Executive
Branch Agencies ........................................................................... 27
5. Mental Health and Behavioral Health Workforce ............................. 31
Background ..................................................................................... 31
Texas’ Need for Mental Health Services ................................................ 34
Children ...................................................................................... 34
Adolescents ................................................................................. 34
Adults ......................................................................................... 35
Texas’ Mental Health Workforce .......................................................... 362

Mental Health Workforce by Profession Among Racial/Ethnic Categories,
Texas, 2019 ............................................................................ 36
Overview of Mental Health Workforce by Profession ........................... 37
Policy Recommendations for the Legislature, the Governor, and Executive
Branch Agencies ........................................................................... 45
6. Teleservices and Technology ........................................................... 53
Defining Teleservices ......................................................................... 53
Use of Teleservices in Texas ............................................................... 53
COVID-19 and the Expansion of Teleservices ......................................... 54
Benefits of Teleservices...................................................................... 55
Access to Teleservices ....................................................................... 56
Access in Rural Counties ................................................................ 56
Providers’ Ability to Deliver Teleservices ........................................... 56
Teleservices Post-COVID-19 ............................................................... 57
Policy Recommendations for the Legislature, the Governor, and Executive
Branch Agencies ........................................................................... 58
7. List of Acronyms .............................................................................. 60
Appendix A. Statewide Health Coordinating Council Roster ................. 62
8. References ...................................................................................... 64

3

1. Executive Summary
By November 1 of even-numbered years, the Statewide Health Coordinating Council(SHCC) directs and approves the development of the Texas State Health Plan or its
updates for submission to the Governor. This plan, following the legislatively
determined purpose of the SHCC, a seeks to ensure that the state of Texas
implements appropriate health-planning activities and that health care services areprovided in a cost-effective manner throughout the state.
This State Health Plan focuses on how different factors affect health equity in thestate of Texas. The plan contains four sections that examine which groups are more
likely to have poorer access to care. The sections look at the challenges faced byindividuals residing in rural areas of the state, mental and behavioral health and theability of the state’s behavioral health care workforce to address these issues, andfinally, the role that teleservices can play in addressing health disparities.
Additionally, each section considers how COVID-19 has impacted health care in
Texas.
Based on the evidence contained within each chapter, the SHCC makes policy
recommendations consistent with goals of improving health care services in thestate and ensuring those services are cost-effective for Texans. These
recommendations include:a●

Access to Care: The state should support efforts to increase enrollment in Medicaid among
those that are eligible.
 The state should examine the varied causes that limit access to care for
Texans.

●Rural Health: The state should support new and innovative ways to bring health careproviders to rural areas.
 The state should support new and innovative methods of hospitalfinancing.

See Texas Health and Safety Code Chapter 104 and Chapter 105.

4

●

Mental Health and Behavioral Health Care Workforce: The state should support efforts by schools to increase access to mental
health services for students.
 The state should continue to support the work of the Texas Child Mental
Health Care Consortium.
 The state should support efforts to increase the funding and stipends
available to students of the mental health professions as they complete
their education and training, as well as support the expansion of the Loan
Repayment Program for Mental Health Professionals.

●

Teleservices and Technology:
 The state should support new and innovative ways to get teleservices torural communities.
 The state should encourage state, federal, and private health insuranceorganizations to promote their teleservice benefits.

5

2. Background
With an eye toward improving access and health care delivery systems throughout
Texas, the 2023-2028 Texas State Health Plan provides guidance on how to achievea high-quality, efficient health system that serves the needs of all Texans.
Specifically, the plan identifies challenges in ensuring that a population as large anddiverse as Texas’ has access to the health care system, that health care services
are provided in an efficient and orderly manner, and that an ample health care
workforce exists to provide these services.
The plan is divided into four sections, each examining health challenges faced by
Texas and its health care workforce and proposing solutions to these challenges.
The first section focuses on issues related to differences in access to care forindividuals across the state. The second section places focus on unique health careissues faced by those who live in rural Texas. The third section examines mental
health and behavioral health issues as well as ways to bolster the health care
workers in this field. The final section examines the impact of teleservices andtechnology on the health care field, as well as how teleservices and technology may
aid in improving access to care.

6

3. Access to Care
This section discusses the health outcomes, health disparities, and demographic
differences among the Texas population. Additionally, the unique challenges faced
due to COVID-19 are discussed.

Defining Access to Care
Throughout much of Texas and the nation, access to health care is restricted by theavailability of providers, resulting in federal designations of health professional
shortage areas (HPSAs). This definition of access relies on the idea that those whoneed health care can access the system if there is an adequate supply of services,
measured by the number of physicians, hospital beds, or some other metric.1 Yetthese geographic designations do not fully reflect the multifaceted concept ofaccess to care. The Institute of Medicine has proposed the definition of access as“timely use of personal health care services to achieve the best possible
outcomes”.2 In addition to the availability of providers, this definition adds
components of timeliness and quality, the latter in the form of positive outcomes.
Another proposed definition of access is “fair access to consistently high quality,
prompt and accessible services right across the country”,1 introducing the importantconsideration of equity. This consideration is important given estimates that 30
percent of direct medical expenditures can be attributed to health disparities thatcreate a sicker population and that these disparities are associated with barriers toaccessing care.3
The successful performance of health care systems at local, state, and national
levels is shown through the ability of individuals to access care when needed.4
Simplistically, access may be considered the ease with which consumers andcommunities are able to use appropriate services in proportion to their needs.
Access can then be considered in economic or other terms, such as the timerequired to utilize health care services, travel distance to services, familiarity withthe health system and providers, and other considerations.1,2,4 Researchers 4,5 haveproposed similar schema for categorizing potential barriers to access. Synthesized,
they are as follows:•

Affordability – Affordability refers to the ability of the patient to pay the
economic costs associated with health care. This may refer to directly

7incurred costs or those associated with insurance coverage, including
premiums, deductibles, etc.
•

Availability – Availability refers to the level of fit between the patient’s healthcare needs and the ability of the system to fit these needs. For example,
availability is a measure of the nearness and capacity of clinicians and clinicalfacilities.

•

Acceptability – Acceptability refers to the ability of patients to interact withthe health care system in light of social, cultural, linguistic, and other norms
that may impede utilization.

•

Appropriateness – Appropriateness refers to the extent to which the services
available fit the needs of the client. On the one hand, appropriateness may
refer to the patient’s level of comfort with the organization of the healthsystem, such as procedures necessary to garner an appointment, available
office hours, etc. On the other hand, this category may also include caremeeting the patient’s expectations with respect to elements such as
timeliness, the amount of time spent developing a diagnosis and treatment
plan, and the technical and interpersonal quality of the services rendered.

•

Approachability – Finally, approachability refers to the extent to which
patients with health care needs are able to identify the appropriate services
available, are aware of how to reach them, and recognize the potential
impact on their health.

Of note, only one of the categories listed above is related to financial capacity of
the individual to pay for health care. While financial barriers to access are importantand associated with the presence of non-financial barriers, it is worthwhile to notethat of those reporting barriers to care, 66.8 percent of U.S. adults reported nonfinancial barriers to care, a rate higher than those reporting financial barriers.4
Seventy one percent of Medicaid patients and 49 percent of Medicare patients
reported non-financial barriers to accessing care.
With respect to availability, one of the main barriers to access that exists is a lackof specialists and subspecialists in low-income and rural areas. For example, one
survey found that 91 percent of community health centers struggled to findadequate off-site subspecialty care for their uninsured patients.6
A major concern regarding acceptability is the extent to which patients are able toreceive information and instructions in their preferred language. Often linguistically8based barriers can result in the delay or even denial of services, challenges withmedication management, and the underutilization of preventive services.7 The
National Committee for Quality Assurance and the Joint Commission on the
Accreditation of Healthcare Organizations are beginning to recognize the role that
language services play in the provision of quality health care. Clinical staff may
need training on when to request a medical interpreter, as unqualified interpreters
may lead to medical errors and poor patient understanding and adherence.
With respect to appropriateness, research2 has noted that patients often experiencea cumulative burden of barriers and are frequently in need of multiple avenues
through which to access care. For example, offices seeking to increase
appropriateness might work to reduce wait times for appointments, alter their officehours to reflect the needs of their clients, and offer advice by phone whereappropriate: all key components of the patient-centered medical home. Researchon community health centers, which often serve populations with low access, show
greater patient satisfaction not only with hours of operation but with overall care.
Finally, approachability relies on the patient to recognize when they are in need ofhealth services and to utilize these services, a term referred to as patient
activation.8 Of note, different rural populations may require different strategies for
ensuring patient activation, and rural populations are likely to require different
strategies than metropolitan areas.4,8 Ultimately, access to healthcare is a complex
idea that can be understood through all of the definitions provided.

Populations with Poor AccessIn all, 18 percent of US adults experienced financial access barriers and 21 percent
experienced non-financial barriers.5 Such barriers have been growing in the past
decade, resulting in decreased likelihood of adults having a usual source of care,having recently seen a dentist, and having recently had a medical office visit.9
Generally, poor access is higher in lower-income, non-white, and young adult
populations, in addition to individuals with at least one chronic disease.5,10 Some ofthese access challenges are related to affordability as racial and ethnic minorities
often comprise a disproportionate percent of the uninsured, despite absolute andrelative improvements in the rates of insurance coverage of Hispanics and African
Americans.10,11 Indeed, reports show that access to care declined in all adult
populations from 2000 to 2010 with the most dramatic declines present inuninsured populations.9 Thus, it comes as no surprise that being uninsured isassociated with foregoing needed care because of cost, not having a usual source ofcare, not receiving recommended screening activities, high-risk adults not getting
9checkups in the past two years, and patients with diabetes not receiving
recommended diabetes care.12
According to the Institute of Medicine13, uninsured pregnant women receive fewer
prenatal care services than insured pregnant women and are more likely to havepoor birth outcomes, including low birthweight and prematurity. Following
pregnancy, women need ongoing care for both physical and behavioral healthneeds, including treatment for chronic conditions such as diabetes andhypertension, as well as diagnosis and treatment for postpartum depression andsubstance use disorders. Women without health insurance often lack access toaffordable contraceptives, including the most effective forms known as Long-Acting
Reversible Contraceptives, which includes intrauterine devices and implants.
Without access to contraceptives women are more likely to experience unintended
pregnancies. Further, uninsured women with breast cancer are 30–50 percent more
likely to die from cancer or cancer complications than insured women with breast
cancer. Uninsured women are 60 percent more likely to receive a diagnosis of latestage cervical cancer.13
Additionally, considerably more Hispanic and multiracial families reported needingan interpreter than white families.11 These barriers may partially explain why lower
proportions of Hispanics, African Americans, and multiracial children receive needed
medical and dental care and why access to specialty care is worse for Hispanics andAfrican Americans.

Texas Populations with Poor Access
Women and Men
Women and men in Texas have unique issues that affect access to health careservices. When compared to men, women have similar rates of health insurance bytype with 62.3 percent carrying private insurance, 17.3 percent with
Medicaid/Children’s Health Insurance Program (CHIP), and 16.8 percent
uninsured.14 The percentages of men who are uninsured are similar, with 18.4
percent uninsured. Texas men are less likely to have a personal doctor whencompared to women, with 28.9 percent of women and 37.6 percent of men
reporting not having at least one personal doctor or health care provider.15 On theother hand, women have reported higher rates of not being able to access medicalcare due to costs, 17.2 percent compared to 13.0 percent of men.
When considering geographic distribution, men and women in border areas havehigher rates of uninsuredness than those in non-border areas.16 While 24.5 percent
10

of both men and women in the state of Texas report not having health carecoverage, 37.9 percent of those living in border areas report not having coverage.
Furthermore, uninsuredness is higher for women than men in non-border areas,
with 42.0 percent of women reporting that they do not have coverage, while 33.8
percent of men reported that they do not have coverage.

Low-Income and Less Educated Populations
Health care access for low-income Texans varies based on socioeconomic position.
Over 44 percent of Texans at or below the federal poverty line (FPL) rely on
Medicaid as their primary insurance, while 23.7 percent rely on private insurance.16
Almost 30 percent of Texans living at or below the FPL are uninsured. Use of
Medicaid is less common as socioeconomic position rises, dropping to 27.2 percent
for families whose income is at 200 percent of the FPL or below. Table 1 shows thepercent of Texans who are uninsured and the percent of Texans that do not have apersonal doctor separated by income.
Table 1. The percent of Texans that are uninsured and do not have a personal
doctor by income level15
Percent Uninsured

Percent that do not have a
Personal Doctor<$25,000

52%

45.7%

$25,000-$49,999

25.6%

34.5%

$50,000-$74,999

20.9%

24.2% b$75,000-$99,999

16%$100,000+

8.7%

Annual Income

The percentage of Texans that are uninsured continues to drop as annual income
increases and lower income Texans are more likely not to have a personal doctor.
Insurance coverage is more likely among higher educated groups.16 For example,
among those aged 25+ years with less than a high school education, 38.8 percent

24.2% of Texans with an annual income of $50,000 or more do not have a personal
doctor.
b

11

reported being uninsured. By comparison, 24.6 percent of high school graduates,
15.7 percent of those with some college, and 7.9 percent of college graduates
reported being uninsured. Likewise, 22.1 percent of those without a high school
degree reported having been unable to see a doctor when they needed to becauseof cost.15 For high school graduates, the percentage was 15.0 percent. For thosewith some college and college graduates, the percentages were 16.3 percent and9.8 percent respectively.

ChildrenEleven percent of Texas children, 854,340 individuals, do not have healthinsurance.16 For those with health insurance coverage, 53.2 percent use private
health insurance and 37.9 percent are enrolled in Medicaid/CHIP. Children that
reside in households that earn 300 percent of the FPL or below have uninsured
rates between 12 and 17 percent while those above 300 percent of the FPL haveuninsured rates of 6 percent.15

Adult Populations
Texans between the ages of 19 to 44 are uninsured at rates that fall between 25.1
and 30.2 percent.16 For Texans that fall in the 45 to 54 year age group, only 20.6
percent reported having no health insurance coverage. For those 65 years of age orolder, only 1.8 percent reported no health insurance coverage. Over half of younger
Texans ages 18 to 29 do not have a personal doctor compared to 43.7 percent for
those ages 30 to 44, 24.7 percent for those 45-64, and 9.1 percent for those ages
65+. Between 16.5 and 19.1 percent of Texans aged 18 to 64 reported that they
were unable to see a physician due to costs. Only 5.3 percent of those aged 65+
were unable to see a physician due to costs.15

Minority Groups
Hispanics in the state of Texas have significantly higher rates of being uninsured
when compared to other racial groups. The percentage of Hispanics that do nothave health insurance coverage is 27.3, compared to 10.0 percent of whites, 15.0
percent of African Americans, and 11.4 percent from other racial backgrounds.16
White and African American Texans are more likely to have a personal doctor (75.6
percent of whites and 76.4 percent of African Americans), when compared to
Hispanics at 52.9 percent. Percentages of Hispanics and African Americans thatwere unable to access a physician due to costs were similar, at 20.2 and 14.7
percent respectively, while only 11.3 percent of whites and 12.2 percent of multiracial or other-raced individuals were unable to see a physician due to costs.15
12

Border Counties c
Texans that reside near the Texas/Mexico border are less likely to have healthinsurance coverage when compared to the state as a whole, 37.9 percent compared
to 24.5 percent.16 When considering only those aged 18-64 in non-border areas ofthe state, those who were uninsured was estimated to be 21.9 percent. In borderareas, this percentage was almost doubled at 38.5 percent. The border region also
has higher rates of Medicaid utilization when compared to the rest of Texas, 27.3
percent compared to 16.2 percent. Additionally, those living in border areas are lesslikely to have a personal health care provider, more likely to forgo needed medical
treatment because of cost, and less likely to have had a routine checkup in the past
year.15

COVID-19 and Access
Nationwide AccessCommunities across the U.S. and specifically in Texas have been impacted by
COVID-19, with communities being impacted in different ways.17 Due to the highdemands of COVID-19 on medical staff, many individuals have reported
experiencing reduced access.18 This issue was particularly severe in the earlier
months of the pandemic. According to experimental survey research, in June andJuly of 2020, 38.7 percent of adults reported that they were unable to receive one
or more types of care in the past two months due to the pandemic. This percentage
dropped to 28.2 percent in August 2020. In May and June 2021, it had fallen
further to 12.7 percent. According to the study, in each time period, women weremore likely than men to report that the pandemic had caused them to be unable toreceive one or more types of medical care.18 Furthermore, the onset of COVID-19
resulted in 5.4 million lost jobs in the U.S. and for many Americans the loss of a job
also resulted in the loss of health insurance, reducing millions’ access to healthcare.19

Border area is defined through the La Paz Agreement of 1986 and includes 32 Texas
Border counties: Brewster, Brooks, Cameron, Crockett, Culberson, Dimmit, Duval, Edwards,
El Paso, Frio, Hidalgo, Hudspeth, Jeff Davis, Jim Hogg, Kenedy, Kinney, La Salle, Maverick,
McMullen, Pecos, Presidio, Real, Reeves, Starr, Sutton, Terrell, Uvalde, Val Verde, Webb,
Willacy, Zapata, and Zavala.
c

13

Access in Texas
According to one study, an estimated 659,000 Texans lost health insurance as aconsequence of job-loss due to COVID. Another study suggests the number of jobs
lost may be even higher, indicating that as many as 1.6 million Texans lost theiremployer-sponsored health insurance due to job-loss during the COVID-19
pandemic.20 Such losses during the pandemic are particularly concerning because
when individuals are without health coverage they tend to delay seeking medical
attention.19 This may have led to additional spread in the virus among those who
did not know that they were infected.

Race & Ethnicity
Additional concerns around COVID-19 relate to differences in vaccination rates
based on race. One major concern, particularly early in the vaccination distribution
process, was ensuring that communities had equal access to the vaccine.21 As of2022, in Texas, 53 percent of white individuals have received at least one dose of
the vaccine, while only 46 percent of African-American individuals have been
vaccinated. In contrast, 59 percent of Hispanic individuals have been vaccinated,and 73 percent of Asian individuals have been vaccinated in Texas.22 Nationally, 48
percent of white individuals, 32 percent of African-American individuals, 27 percent
of Hispanic individuals, and 48 percent of Asian individuals have received at least
one dose of the vaccine.23 Texas exceeds vaccination rates among race/ethnicity
categories compared to the nation as a whole.

Strategies for Improving AccessThree broad strategies are available to address the gaps in access to care identified
above: improving rates of insurance coverage; increasing the availability of healthcare professionals, facilities, and services; and a reduction in social barriers to care.
Ultimately, improving timely access to and quality of care will depend on
collaboration among local clinicians, hospital leaders, insurance companies,
policymakers, and community stakeholders.12 Success in improving access to carerelies on concurrent efforts to reduce financial and nonfinancial access barriers.5
Additionally, Texas has fewer physicians per capita than the national average,
creating additional hurdles for those who need access to care.24 Increasing thenumber of available physicians and other health care providers will improve accessand lessen the burden on those health care professionals in the state. A
fundamental aim of the redesign of primary care services is improving access tocare. Patients who reported having a usual site of care and a provider at that site14

are more likely to access that care, receive preventive services, and have improved
health.2 The following strategies seek to improve access by making health caremore affordable, available, acceptable, appropriate, and approachable.

Covering More Texans
In order to improve the affordability of care and thus access in Texas, it should be apriority of this state to increase the number of Texans with insurance coverage anda usual source of care. This can be accomplished through greater public coverage ofthe poor and improved access to physicians and other providers within the public
system. Projections25 demonstrated that low-income Medicaid enrollees weresignificantly more likely to have a usual source of care and less likely to haveunmet health care needs. Publicly covered adults are also more likely to report
timely care and less likely to delay or go without needed medical care because ofcosts.
With respect to mothers and their children, increasing the percentage of covered
mothers is likely to have a significant effect on access to health care, ability to pay
medical bills, and mental health. Children are also expected to benefit, since theircoverage and access to care have been shown to improve when their parents havecoverage. Increasing the number of mothers with insurance may also improveoutcomes for children in other ways, such as by reducing maternal depression,
which can affect parenting abilities.
Medicaid, along with its companion CHIP, is a state/federal partnership thatprovides health care coverage to low-income children and their caretakers,
pregnant women, people age 65+, and people with disabilities. Some states,
though not Texas, have chosen to extend Medicaid coverage to childless,nondisabled, working age adults.
In Texas, the Medicaid and CHIP programs cover over four million people.26 A large
body of evidence suggests that these individuals are more likely to have a usual
source of care, more likely to receive preventive health services, and less likely tohave unmet or delayed needs for medical care than if they were uninsured.25
Research has consistently indicated that people with Medicaid coverage fare muchbetter than their uninsured counterparts on measures of access to care, utilization,and unmet needs. Evidence further shows that, compared to low-income uninsured
children, children enrolled in Medicaid are significantly more likely to have a usual
source of care and to receive well-child visits and immunizations, and significantly
less likely to have unmet or delayed needs for medical care, dental care, andprescription drugs due to costs. Moreover, in some states that expanded Medicaid,15

reports note that the expansion led to improvements in prenatal care use, in termsof either earlier or more adequate prenatal care.
The federal government currently subsidizes, via tax credit, marketplace healthinsurance premiums for households that earn from 100 percent to 400 percent of
the FPL.13 Texas adults earning below the FPL, but who do not qualify for Medicaid
or for federal subsidies to purchase care on the insurance exchange, fall into what
is known as the “coverage gap.” Nationally, over two million poor uninsured adults
fall into the coverage gap, a third of which reside in Texas. In total, there are
771,000 people that fall into the coverage gap in Texas, leaving them with norealistic options for affordable health insurance coverage.

Provider Participation in Medicaid
In order to improve access to care in Texas, it is important to address shortages inproviders treating low-income individuals. Among the challenges providers face are
the administrative burden of participation in Medicaid, the complexity of many
patients’ needs, challenges in arranging mental health and specialty referrals, large
patient panels associated with a general shortage of physicians, and lower
reimbursement rates than other payers. National research has indicated thatphysicians may be optimistic about the ability of electronic health records andmedical homes to mitigate challenges.27
With respect to reimbursement, Texas is one of 22 states that pays 75 percent orless for Medicaid physician fees when compared to Medicare physician fees.5 Thereare 24 states that pay physician fees at 75 percent to 100 percent and three thatpay greater than 100 percent for services under state-run Medicaid programs whencompared to Medicare. Texas Medicaid pays approximately 65 percent compared to
the federally funded Medicare program.3 Due to the gap in physician reimbursement
between the two programs, physician participation has diminished. The number ofTexas physicians willing to accept new Medicaid patients fell from 67 percent in2000 to 31 percent in 20124 and increased slightly to 34 percent in 2015.1,3 In
order to guarantee strong provider networks for Texas low-income residents, Texasshould strive to pursue a comprehensive approach to improving provider experienceand increasing participation in Medicaid.
From 2013 to 2014, the federal government provided additional funding thatallowed states to increase Medicaid payments to primary care physicians to match
payments for the same services through Medicare.28 These funds successfullysought to increase participation in Medicaid programs, especially primary care16

services, effecting a five percent rise in physician participation in Medicaid during
this time.1,3 However, the increase in payments was not made permanent in Texas.

Other Policy Considerations
Generally, the racial and ethnic profile of health care providers in Texas does notreflect that of the population at-large. In addition to cultural preferences ponderedin the mental health section of this report, it has been shown that minority
physicians are significantly more likely to care for minorities, the publicly insured,and uninsured patients.11 Likewise, a more diverse workforce may help address theneed for linguistic competency within the health provider workforce. In the interim
though, the standardization of payment mechanisms for interpreter services andtheir inclusion in health plans may improve access for those who are not proficientin English.7
The expansion of teleservices, the appropriate utilization of physician assistants andadvanced practice registered nurses, and stronger financial incentives for clinicians
to practice in underserved areas may be useful for expanding access in
geographically underserved areas.5

Policy Developments
The Delivery System Reform Incentive Payment (DSRIP) pool in the Texas
Healthcare Transformation and Quality Improvement Program Medicaid 1115
Demonstration (Waiver) began in 2012 and was set to conclude in September
2021.29 The DSRIP program benefitted Texans and the Texas health care delivery
system. Texas providers earned over $15 billion in DSRIP funds from 2012 toJanuary 2019, and it served 11.7 million people and provided 29.4 million
encounters from October 1, 2013 to September 30, 2017. As the DSRIP pool cameto a close, the state of Texas began working on new programs to support services
in Texas. As part of the DSRIP transition plan, several programs that offer access tocare, often for underserved communities, have been introduced. The Health andHuman Services Commission (HHSC) submitted the following programs, which havebeen approved:●

Texas Incentives for Physician and Professional Service (TIPPS)30: A valuebased directed payment program for certain physician groups providing
health care services to children and adults enrolled in the STAR, STAR+PLUS

17

●

●

●

and STAR Kids Medicaid programs. d Eligible physician groups include healthrelated institutions, indirect medical education physician groups affiliatedwith hospitals, and other physician groups.
Comprehensive Hospital Increased Reimbursement Programs31: A directed
payment program for hospitals providing health care services to adults andchildren enrolled in STAR and STAR+PLUS. Eligible hospitals include
children's hospitals, rural hospitals, mental health hospitals, state-owned
hospitals, and urban hospitals.
Directed Payment Program for Behavioral Health Services32: A directed
payment program for community mental health centers to promote andimprove access to behavioral health services, care coordination, andsuccessful care transitions. It also incentivizes continuation of care for STAR,
STAR+PLUS, and STAR Kids members using the Certified Community
Behavioral Health Clinic model of care.
Rural Access to Primary and Preventive Services33: A directed payment
program for rural health clinics that provide primary and preventative careservices to STAR, STAR+PLUS, and STAR Kids members.

Policy Recommendations for the Legislature,
the Governor, and Executive Branch Agencies
Encourage the use of health care teams that include different types ofhealth care providers.
In 2021, 34 of the 254 counties in Texas had no primary care physicians and 31
counties had no direct patient care physicians.24 Using teams that include different
types of health care providers can facilitate the provision of care for those without
physicians nearby. Using teams also promotes more efficient care in addressing thehealth care needs of patients and provides physicians with the opportunity to focus
on the more serious and complex needs of patients. This shift would help toredistribute responsibilities and allow physicians to utilize their time working withthose patients who need their expertise. This would allow physicians to more
efficiently allocate their time, which is critical due to the shortage of physicians inthe state.

STAR, STAR+PLUS, and STAR Kids are Texas Medicaid and CHIP Programs. Moreinformation about the individual programs can be found athttps://www.hhs.texas.gov/services/health/medicaid-chip/medicaid-chip-members.
d18

Conduct a study examining which factors decrease physician participationin Medicaid programs.
Improving our understanding regarding why more physicians do not participate in
Medicaid is an important first step in increasing access. Many factors may influencephysicians’ decision to not participate in Medicaid programs, such as the process of
becoming a Medicaid provider, patient participation, reimbursement rates, etc.
Understanding the hurdles preventing physicians from participating will allow for
more targeted approaches in improving physician participation in Medicaid which
would improve access for many Texans.
Support the furthering of health literacy and utilization of preventative
services for those on Medicaid.
According to the CDC, health literacy is “the degree to which individuals have theability to find, understand, and use information and services to inform healthrelated decisions and actions for themselves and others.”34 Furthering healthliteracy would aid in improving health outcomes.35 Research has shown thatpatients who are better informed make better choices for their health, ultimately
improving health outcomes. Health literacy is also key for effective preventative
medicine.36 Health literacy helps prevent health problems, protect individuals’
health, helps people better manage health problems when they arise, and improves
individuals’ ability to identify health problems early, which is often key totreatment.37 Additionally, preventative medicine improves health outcomes, andincreasing the utilization of such services would improve the health of Texans.38
During the 87th Legislature, Regular Session, the House Select Committee on HealthCare Reform was created. The committee’s duties are to “examine the potential
impact of delayed care on the state’s health care delivery system, health care costs,
and patient health outcomes, as well as best practices for getting patients withforegone or delayed health interventions back into the health care system. The
study should consider patient delays in obtaining preventative and primary healthservices…” Together, improving health literacy and utilization of preventative
services for those on Medicaid could improve the health of Texans across the state.
Support efforts to increase enrollment in Medicaid among those that are
eligible.
During the 87th Legislature, Regular Session, the House Select Committee on HealthCare Reform was created. The committee is charged with studying ways to improve19

outreach to families with children who are eligible for, but are not enrolled in,
Medicaid or CHIP. This targets increasing enrollment of children who are eligible,
but there should also be similar efforts to increase outreach for all those who are
eligible for Medicaid but not enrolled in the program.
Continue to support programs like TIPPS, which provides increased
Medicaid payments to certain physician groups providing health careservices to persons enrolled in STAR, STAR+PLUS, and STAR Kids.
On March 25th, 2022 the TIPPS program was approved by the Centers for Medicare
and Medicaid Services.32 This program is for delivery system and provider payment
initiatives under Medicaid managed care plan contracts. Three classes of providers
are eligible to participate: (1) health-related institution physician groups, (2)physician groups affiliated with hospitals that receive indirect medical education
funding, and (3) other physician groups.
TIPPS funds are paid through three components of the managed care capitation
rates:•

Component 1 is equal to 65 percent of the total program value and provides
a uniform dollar increase paid monthly. Only health-related institutions andindirect medical education physician groups are eligible for Component 1.

•

Component 2 is equal to 25 percent of the total program value and provides
a uniform rate increase paid semi-annually. Only health-related institutions
and indirect medical education physician groups are eligible for Component 2.

•

Component 3 is equal to 10 percent of the total program value and provides
a uniform rate increase for applicable outpatient services and is paid at thetime of claim adjudication. All participating physician groups are eligible for
Component 3.

Increased Medicaid payments compensate providers and may encourage greater
participation in the programs, which would increase the capacity to provide care to
those on Medicaid.
Support the development of quality thresholds that must be met by those
providers participating in TIPPS.
The TIPPS program has the following quality goals:

20

•

•

Promote optimal health for Texans at every stage of life through prevention
and by engaging individuals, families, communities, and the health caresystem to address root causes of poor health.
Promote effective practices for people with chronic, complex, and serious
conditions to improve people’s quality of life and independence, reduce
mortality rates, and better manage the leading drivers of health care costs.

Subsequently, TIPPS providers must provide qualitative and numeric data, which
will be used to monitor provider-level progress toward state quality objectives.
While these quality measures must be reported, there are no minimums thatcurrently must be met so there should be a shift to developing standards that would
assess whether care is meeting or exceeding the quality goals that have beendeveloped.
Examine the varied causes that limit access to care for Texans.
While affordability plays a role in access to care, it is only one factor to consider
when examining barriers to health care. Lawmakers should further examine otherfactors that limit access to care. This includes the level of fit between patients’
health care needs and the ability of the system to fit these needs, which includes
the nearness and capacity of clinicians and clinical facilities.5 Another factor thatshould be examined is the ability of patients to interact with the health care system
in light of social, cultural, linguistic, and other norms that may impede utilization.
These factors are particularly important due to the large Hispanic population in thestate. Texas had a higher percentage of individuals five years of age and over who
spoke a language other than English at home (35.5 percent) compared to thenation (21.5 percent) from 2014 to 2018.39 Texas has the second highest
percentage of individuals who spoke a language other than English at home (behind
California). The most common language other than English spoken at home in
Texas was Spanish (29.5 percent), followed by Asian and Pacific Islander languages(2.9 percent) and other Indo-European languages (2.2 percent).
Additionally, the extent to which the services available fit the needs of the patient
should also be examined.5 This may include the patient’s level of comfort with theorganization of the health system. It may also include care meeting the patient’s
expectations with respect to elements such as timeliness, the amount of time spentdeveloping a diagnosis and treatment plan, and the technical and interpersonalquality of the services rendered. Finally, the extent to which people with health careneeds are able to identify the appropriate services available, are aware of how to21reach them, and recognize the potential impact on their health should be included
when examining access to care.

22

4. Rural HealthThis section discusses the health outcomes, health disparities, and demographic
differences in rural areas throughout the state of Texas. Additionally, the uniquechallenges faced by hospitals and health practices are discussed.

Health Outcomes in Rural Areas
Nationally, residents in rural areas have a life expectancy 1 to 5 years less thanresidents in urban areas.40 Those in rural areas are more likely to smoke, less likely
to exercise, and have less nutritional diets than those in suburban areas.41 These
factors contribute to higher mortality rates and higher rates of chronic diseases inrural areas. Approximately 43 percent of deaths in rural areas can be attributed tomodifiable risk factors such as smoking, excessive drinking, and obesity, compared
to about 37 percent in urban areas.42 Rural residents are more likely to havehypertension, diabetes, arthritis, and high cholesterol than urban residents. Rural
children are more likely to be obese than urban children.43 Rural areas also havehigher age-adjusted mortality for heart disease, cancer, chronic respiratory disease,and stroke.44 In 2019, the age-adjusted mortality was 834.0 per 100,000
population in rural communities and 693.4 in urban communities.45 Rural residents
were also more likely to die due to unintentional injury, drug poisoning, and suicide
than urban residents.
Rural health in Texas faces both similar and unique challenges compared to rural
health nationally.46 The rural populations of Texas are incredibly diverse; forexample, the Texas-Mexico border area is predominantly Hispanic (88.4 percent)compared with the rest of the state (35.5 percent).47 There are colonias, which are“residential area[s] lacking some basic infrastructure like a drinking water supply,
sewage treatment, paved roads, adequate drainage, etc.”48 Adult residents ofcolonias report worse physical health compared to adults nationally and Hispanic
adults as a whole.49

COVID-19
The first pandemic surge in Spring 2020 resulted in higher incidence and mortality
in urban areas. During the second surge in Summer 2020, the rates in rural areas
surpassed those in urban areas. Since then, incidence and mortality rates haveremained higher in rural than urban areas.50 Rural areas felt a greater impact fromCOVID-19 due to poor health literacy and health care infrastructure, as well as
23

having higher proportions of elderly and people with comorbidities.51 Rural areas
have higher incidences of underlying medical conditions that increase the risk ofsevere illness from COVID-19, such as obesity, diabetes, hypertension, andsmoking.52 Rural areas also tend to have lower COVID-19 vaccination rates.53
Residents of rural areas are more likely to distrust vaccines than those of urban
areas.54

Emergency Medical Services
Emergency medical services (EMS) face challenges in rural Texas.55 As
requirements for EMS personnel increase and access to training in rural Texas
decreases, this exacerbates staffing issues in rural Texas. Rural EMS providers tend
to be staffed less than urban EMS. EMS agencies are often staffed by volunteers ora mix of volunteers and paid staff. One study found that those agencies staffed byvolunteers are often less trained and would benefit from additional training for theirpositions.56 Additionally, a study found that rural EMS are more likely to lose staff
to burnout than urban EMS. The closure of rural hospitals also puts strain on EMS
by increasing drive times to facilities.57 The Texas Department of Transportation
Safety Division through the Texas A&M Engineering Extension Service provides
funding for Texas Rural/Frontier EMS training; however, funds are limited.55 Senate
Bill 8 of the 87th Legislative Session, 3rd Special Session, allocated funding for EMS
education programs.58 This included $21 million that goes towards scholarships for
EMS students with special consideration for those in rural parts of Texas.59

Teleservices
The current COVID-19 pandemic has resulted in the rapid expansion of telehealthand telemedicine services. The Centers for Medicare and Medicaid Services has
expanded the number of services eligible for telehealth.60 Additionally, emergency
rules were issued expanding telehealth and telemedicine.61 A report identified
telemedicine as a way for rural residents to access subspecialist services and for
expanding services offered by nurse practitioners and physician assistants.62
Broadband access is a barrier to receiving telehealth and telemedicine in rural areasof Texas.55 There are over 2 million households in Texas without high-speed
internet access.63 Fiber infrastructure and broadband access have been identified asa key concern among rural residents.55

Older Adults in Rural Areas
Nationally, the rural population is older than the urban population.64 In 2015, themedian age was 51 years in rural areas and 45 in urban areas. Rural communities
24

also had a higher proportion of people aged 65 and older in 2016, as this age group
comprised 18.4 percent of the population in rural areas compared to 14.5 percent
in urban areas. According to the Texas Demographic Center, rural counties
experienced the greatest increases in median age from 2010 to 2018.65 For
instance, 18 percent of rural counties saw an age increase of two to four years, and16 percent saw an increase of more than four years. Metropolitan counties saw an
age increase of two to four years in 13 percent of counties and more than four
years in only 2 percent of counties. Older adults are at higher risk of chronic
disease, and many manage two or more chronic conditions.66 Older adults often
require more complex health care that may be more difficult to receive in rural
areas.

Challenges for Low-Income and Uninsured Populations in
Rural Areas
In 2018, Texas had the highest number of uninsured people in any state.67 Rural
households also report a lower median income than urban households.64 In 2016,
the median income was $46,000 for rural households and $62,000 for urbanhouseholds. Moreover, the poverty rate was 16.9 percent in rural areas and 13.6
percent in urban areas. In 2013, the food insecurity rate was 15.8 percent in ruralcommunities and 14.5 percent in urban communities. Low-income communities
have limited access to fresh foods and environments that are conducive to physicalactivity.68 Income and poverty have been established as being associated with poor
health and increased mortality.
In summation, people that live in rural areas tend to have poorer health outcomeswhen compared to their urban counterparts. These issues are highlighted by thelower incomes and lower insurance rates in rural areas. These issues make rural
health access complex and highlight why the issues surrounding facilities andproviders, as discussed below, are particularly important.

Hospital and Nursing Facility Closures
Access to quality health services was identified as the top priority in rural healthover the last decade.46 Types of access that were identified as the most concerning
include emergency services, primary care, and insurance. Since 2010, 26 rural
hospitals have closed in Texas.69 Hospital closures in rural areas negatively impact
access to care and potentially health outcomes as well.70 Hospital closures lead toloss of access to emergency care, making emergency medical transport even more
important. For patients that rely on hospitals for specialty care or referrals, they25

lose that access as well. In particular, communities often lose access to obstetriccare, mental health care, and diagnostic testing when hospitals close. Communities
that lose hospitals have a difficult time recruiting employers and industries to thearea.
Hospital closures can lead to increases in the amount of time patients must travel
to obtain care.71 Longer travel times can lead to negative health outcomes,
especially for conditions like traumatic injuries and stroke.
There was a significant amount of nursing home closures between June 2015 andJune 2019.72 Research shows there were 555 nursing home closures nationwide
during these years, including 65 in Texas. Moreover, 40 percent of the nursing
home closures in Texas were in rural areas.
In 2018, Texas had the highest number of uninsured people in any state, and Texas
has not expanded Medicaid through the Affordable Care Act (ACA).67,73 People ofcolor are more likely to be low-income and uninsured, so Medicaid expansion
affects them more significantly.75 Additionally, the ACA expansion of Medicaid has
been found to be associated with reduced probabilities of hospital closures.76 In
states that expanded Medicaid, rural hospitals increased revenue that likely reduced
the number of closures.

Providers
Data from the Texas Department of State Health Services (DSHS) indicate that
non-metropolitan counties had 36.7 percent fewer primary care physicians per
capita than metropolitan counties in 2021.24 Non-metropolitan counties had 56.6
percent fewer direct patient care physicians per capita than metropolitan counties.
In the same year, there were 34 counties in Texas with no primary care physiciansand 31 counties with no direct patient care physicians.
Some reasons why health care clinics close include physician retirement or because
they, like hospitals, are not financially solvent. Clinic closures in rural Texas canlead to longer drives to access care and delaying care due to the distance.77 An
example was highlighted in a news article that described the impact of the closureof the clinic in Cottle County that resulted in one resident having to drive 30
minutes to Childress County, the next closest clinic. Residents in rural areas must
make hard choices about whether or not to move to obtain better access to care,
especially as they age.

26

Older Providers
As illustrated by data from DSHS, direct patient care physicians in rural Texas areas
tend to be older.24 In 2021, the median age of direct patient care physicians was 49
years in metropolitan counties and 56 years in non-metropolitan counties.
As physicians in rural areas age and retire, they may leave practices that have toclose because there are no physicians in the area to continue the practice.78 Whenthe nurse practitioner who ran the only health clinic in Memphis, Texas retired, theclinic closed. Now residents must drive approximately 140 miles to receive care.

Obstetric Services
According to DSHS data, non-metropolitan counties had 63.4 percent fewer
obstetricians and gynecologists per capita than metropolitan counties in 2021.24
Projections show that the shortage of obstetricians and gynecologists is projected tocontinue through 2032 in seven of the eight public health regions in Texas.79
Nationally, the number of hospitals providing obstetric care in rural areas has
decreased over the last 20 years.80 This can lead to increased travel time forwomen in rural areas. A study that examined factors associated with rural obstetricunit closures found that common risk factors included: low number of births,
private hospital ownership, low number of family physicians in county, and lower
income county.
As obstetric units close, women must drive farther distances to give birth.80 Thismay be dangerous for women with high-risk pregnancies or complications. Obstetricunit closures in rural counties that are not adjacent to urban counties areassociated with higher rates of preterm births.81

Policy Recommendations for the Legislature,
the Governor, and Executive Branch Agencies
Support new and innovative methods of hospital financing.
Hospital financing is a significant factor in whether a hospital stays in a rural area.
By encouraging innovative financing, Texas can create novel solutions to strengthenrural hospitals. In the report from Texas A&M University, facility conversion is
identified as a solution for hospitals.62 Another model, the Pennsylvania Rural
Health Model, transitions rural hospitals from fee-for-service to global budget
27

payments.82 The Texas A&M University Rural and Community Health Instituteprovides technical assistance to rural hospitals in such areas as finance challenges,
grant writing, and community engagement.83
By evaluating services, hospitals can best adjust their services to meet the needs ofthe community. Additionally, facilities can formalize relationships with otherfacilities to provide other services. Sharing resources such as key personnel, healthinformation technology, and board membership can help to optimize limited fiscal
resources and improve continuity of care.84
Monitor the impact of the coronavirus pandemic on the number ofuninsured people in Texas.
Prior to the coronavirus pandemic, Texas had the highest number of uninsured
people of any state. More than 4.9 million people in Texas, or about 17.3 percent of
the state’s population, were uninsured in 2020.85 An estimated 659,000 adults in
Texas lost coverage due to job loss during the pandemic.86 As this is a rapidlychanging situation, leaders must continue to track and determine the impact of thepandemic on the number of uninsured people in the state.
Monitor the impact of the coronavirus pandemic on the shortage andmaldistribution of health care providers.
A survey conducted by the American Association of Critical Care Nurses found that
92 percent of respondents felt that the pandemic had “depleted nurses at their
hospitals and, as a result, their careers will be shorter than they intended.”87 Many
physicians are also experiencing burnout due to the pandemic.88 Nationally,
employment in the health care field is down by 306,000, or 1.9 percent, since
February 2020.89 This could exacerbate the existing workforce maldistribution in thestate and shortage in rural areas. Notably, the number of Texas counties
designated as primary care shortages areas jumped from 129 in 2019 to 228 in
2021.90
During the pandemic, many nurses left their jobs to become traveling nurses due tohigher earning potential. The nursing shortage has driven up the price of travelingnurses, making employing them much more costly to hospitals that areexperiencing staffing shortages.91 To adequately provide for the medical needs of all
Texans, the state must correct its chronic shortage and maldistribution of healthcare providers.

28Support expanding the state’s loan repayment programs to include more
health professions.
The Texas Higher Education Coordinating Board has loan repayment programs forphysicians, nurses, and mental health professionals who practice in underserved
areas.92 Two of these are the State Physician Education Loan Repayment and Rural
Resident Physician Grant programs. Research by the Association of American
Medical Colleges shows that physicians tend to stay and practice medicine in thearea where they trained.93 The 2016 National Health Service Corps Participant
Satisfaction Survey found that 88 percent of participating clinicians who received
loan repayment assistance in exchange for working in underserved areas stayed inthat area for up to one year after their obligation, and 43 percent intended to stayfor five or more years.94 Expanding the loan repayment programs to include more
health professions could increase the number of people practicing other healthprofessions in underserved areas and incentivize people to enter a healthprofession. These programs should also be advertised to expand their reach.
Support new and innovative ways to bring health care providers to rural
areas.
Rural Americans live an average of 10.5 miles from the nearest hospital, compared
to 4.4 miles for those in urban areas.95 By supporting alternative methods ofbringing health care providers into rural areas, more patients in underserved areas
could receive care. Programs like Care Van, a collaboration between the Caring
Foundation of Texas and other institutions including the Texas Tech University
Health Sciences Center, brings health care providers to communities, including ruralcommunities, at no cost to those who qualify.96
The availability of teleservices must also expand to ensure greater access to healthcare services. There are currently numerous barriers to the practice of telehealthand telemedicine. House Bill 5, 87th Legislature, Regular Session, 2021, establisheda Broadband Development office to improve access to broadband services in rural
areas.97 A Texas A&M University report identified telemedicine as a way for rural
residents to access subspecialist services and for expanding services offered bynurse practitioners and physician assistants.62
Ensure that high school students are educated about the health caresystem and careers in health care.
Health care workers from rural areas are more likely to practice in rural areas.
Therefore, high school students in rural areas should be encouraged to enter the29

health care field.98 They can be provided with education about how the health caresystem works, what careers are available to them in health care, what kind of
preparation is necessary for these careers, and how to apply to training andeducational programs. The Health Professions Recruitment and Exposure at the
University of Texas Southwestern Medical Center accomplishes these goals by“expos[ing] high school students to medicine and science through a variety ofworkshops and hands-on activities.”99
High schoolers can also begin their path toward professional licensure. Seven
vocational nursing programs in Texas offer options for high school students to takenursing courses and become licensed shortly after high school graduation.100
Supporting programs for high school students could increase prospective entrants
into health care fields experiencing workforce shortages.

30

5. Mental Health and Behavioral Health
Workforce
This section covers the growing need for U.S. and Texas mental health services for
distinct demographic categories. In addition, it discusses and displays the shortagesof the behavioral health workforce and the challenges faced for recruitment andretention.

Background
Nationally, almost half of adults (46.4 percent) will experience a diagnosable
mental disorder in their lifetime.101 On an annual basis, over one in four adults(26.2 percent) in the U.S. experience mental illness and about one in 17 (5.8
percent) experience a serious mental illness.102 Half of diagnosable mental disorders
begin by the age of 14 and three-fourths begin by the age of 24.101 Moreover, anestimated 14 to 20 percent of young people annually have mental, emotional, andbehavioral disorders.103
According to the 2020 National Survey on Drug Use and Health, 52.9 million adults
aged 18+ (21.0 percent) experienced mental illness and 14.2 million adults (5.6
percent) experienced serious mental illness in the past year.104 Among children andadolescents aged 12 to 17, 4.1 million (17.0 percent) experienced a major
depressive episode and 2.9 million (12.0 percent) experienced a major depressive
episode with severe impairment in the past year.
The 2020 survey results also indicate that only 46.2 percent of adults who
experienced mental illness and 64.5 percent of adults who experienced serious
mental illness in the U.S. received inpatient or outpatient mental health services or
took prescription medication for a mental health condition in the past year.
Furthermore, an unmet need for mental health services in the past year wasperceived by 30.5 percent of adults who experienced mental illness and 49.7
percent of adults who experienced serious mental illness. Among children andadolescents aged 12 to 17 who experienced a major depressive episode, just 41.6
percent received treatment for depression in the past year.
Additionally, the 2020 survey results indicate that the COVID-19 pandemic
negatively affected mental health. From October to December 2020, the majority ofadults (73.0 percent) and the majority of children and adolescents aged 12 to 1731

(69.1 percent) in the U.S. perceived that the COVID-19 pandemic had a negative
effect on their mental health. For adults as well as children and adolescents aged
12 to 17, 18.3 percent perceived that their mental health was negatively affected“quite a bit or a lot” because of the COVID-19 pandemic. Another 54.7 percent of
adults and 50.8 percent of children and adolescents perceived that their mental
health was negatively affected “a little or some” because of the COVID-19
pandemic.
A national study conducted by the Center for Studying Health System Change foundthat 66.8 percent of primary care physicians were unable to refer their patients tohigh-quality outpatient mental health services.105 This percentage of unavailability
is much higher than the percentages reported by primary care physicians for othercommon referrals, including high-quality specialist referrals (33.8 percent), highquality imaging services (29.8 percent), and nonemergency hospital admissions(16.8 percent). Primary care physicians reported that the unavailability of highquality outpatient mental health services was due to lack of or inadequate healthinsurance coverage, a shortage of providers, and health plan barriers.
Despite the established need for mental health services, a mental health workforce
shortage is evident nationwide. According to the Health Resources and Services
Administration (HRSA), over 148.2 million people in the U.S. live in the 6,222
HPSA’s for mental health.106 Areas designated by HRSA as HPSA’s for mental health
may be based on the ratio of population to psychiatrist, the ratio of population tocore mental health provider (includes psychiatrists, clinical psychologists, clinicalsocial workers, psychiatric nurse specialists, and marriage and family therapists), or
both of these ratios.
●●

If based on the ratio of population to psychiatrist, geographic designations
must have a ratio of 30,000 to 1. In areas with high needs, e geographic
designations or population designations must have a ratio of 20,000 to 1.
If based on the ratio of population to core mental health provider, geographic
designations must have a ratio of 9,000 to 1. In areas with high needs,
geographic designations or population designations must have a ratio of
6,000 to 1.

High needs areas are those that meet specific qualifications on population to provider
ratios, percent of population below the FPL, and/or distance to health care. Moreinformation can be found at Scoring Shortage Designations | Bureau of Health Workforce(hrsa.gov).
e

32

●

If based on the ratios of both population to psychiatrist and population tocore mental health provider, geographic designations must have a population
to psychiatrist ratio of 20,000 to 1 and a population to core mental healthprovider ratio of 6,000 to 1. In areas with high needs, geographic
designations or population designations must have a population topsychiatrist ratio of 15,000 to 1 and a population to core mental healthprovider ratio of 4,500 to 1.

Most HPSA’s for mental health are designated based on the ratio of population topsychiatrist. Estimates show that an additional 7,420 mental health providers would
be needed to remove the existing health professional shortage area designations
for mental health in the U.S.
Demand for mental health services is projected to increase nationwide due to theaging population.107 The number of older adults with mental and behavioral healthproblems is projected to increase by 11 million from 1970 to 2030. Moreover, theaging of the national population requires behavioral health service providers withspecial knowledge and skills.108
HRSA issued national-level supply and demand projections for several behavioral
health occupations from 2016 to 2030 that incorporate estimates of unmet need for
behavioral health services. These projections are based on the unlikely assumptionthat there are no changes in the levels of behavioral health care service provision or
utilization from 2017 to 2030. Based on these projections, there will be an
estimated shortage of 34,940 addiction counselors,109 21,150 adult psychiatrists,
14,300 clinical, counseling, and school psychologists, and 40,140 mental healthcounselors nationwide in 2030. These projections also indicate that there will be an
estimated surplus of 3,720 child and adolescent psychiatrists, 1,650 marriage andfamily therapists, 2,440 psychiatric nurse practitioners, 1,500 school counselors,and 200,280 social workers nationwide in 2030.
Workforce-based explanations for an inadequate supply of mental health andaddiction providers at-large generally focus on insufficient numbers of providers,high turnover, low compensation, a lack of diversity, and limited competency inevidence-based treatments.108 Describing the mental health workforce shortage
quantitatively can be problematic, as relevant data have not been universallycollected and there is no agreed-upon definition of adequate supply.110 However,efforts to describe the mental health workforce shortage should consider both the
population’s need for mental health services and the number of providers available
to deliver these services.
33

Texas’ Need for Mental Health Services
As noted above, one part of describing a workforce shortage involves
demonstrating the needs of the population for mental health services. A standard
definition of mental health need is not available at the state or national level.

Children
No reliable statewide survey data on mental health needs exist for children younger
than high school age. However, data from HHSC indicate that 44,031 children who
were 13 years of age or younger received mental health services from local mental
health authorities in Texas during state fiscal year 2017.111 The top five diagnostic
groups were attention deficit disorder (53 percent), adjustments/other nonpsychotic (9 percent), disruptive behavior disorder (8 percent), affective disorders other (8 percent), and affective disorders - major depression (6 percent).

Adolescents
According to the 2019 Texas Youth Risk Behavior Survey, 38.3 percent of Texas
high school students reported feeling so sad or hopeless almost every day for atleast two weeks in the past year that they stopped doing some usual activities.112
Similar results were reported by age and grade level where high school students 18
years of age and older (46.1 percent) were significantly more likely to report feelingso sad or hopeless almost every day for at least two weeks in the past year thatthey stopped doing some usual activities than those 15 years of age and younger(34.7 percent). Twelfth graders (43.2 percent) were significantly more likely toreport such than ninth graders (32.7 percent). Females (48.6 percent) weresignificantly more likely to report these feelings than males (28.3 percent). No
significant differences were reported by race/ethnicity.
The 2019 survey results also indicate that 18.9 percent of Texas high school
students reported seriously considering a suicide attempt in the past year. Females(25.3 percent) were significantly more likely to report seriously considering asuicide attempt in the past year than males (12.6 percent), and those in the“Other” races/ethnicities category (25.5 percent) were significantly more likely toreport such than Hispanics (16.7 percent). No significant differences were reportedby age or grade level. In addition, 15.0 percent of Texas high school students
reported making a plan in the past year for how they would attempt suicide. While
there were no major differences reported by age, grade level, or race/ethnicity,
females (19.4 percent) were significantly more likely to report making a plan in thepast year for how they would attempt suicide than males (10.6 percent). Results
34

further indicate that 10.0 percent of Texas high school students reported
attempting suicide at least once in the past year and 3.4 percent reported requiring
medical treatment after doing so. No major differences were reported by age,gender, grade level, or race/ethnicity.
The percentage of Texas high school students who reported feeling sad or hopeless,seriously considering a suicide attempt, making a suicide plan, attempting suicide,and requiring medical treatment following a suicide attempt increased significantly
from 2009 to 2019. No significant differences were found between Texas highschool students and high school students nationwide in the likelihood of reporting
feeling sad or hopeless, seriously considering a suicide attempt, making a suicideplan, attempting suicide, or requiring medical treatment following a suicide attempt
in 2019.

AdultsThe 2020 results from the Texas Behavioral Risk Factor Surveillance System15
indicate increases in all categories displayed here as compared to the 2018
results.111Just over 23 percent of Texas adults reported having poor mental healthfor five or more days in the past 30 days. Adults between 18 and 29 years (33.8
percent) were significantly more likely to report having poor mental health for fiveor more days than those between the ages of 45 and 64 (21.1 percent) and adults
who are 65+ years (13.7 percent). Moreover, adults between 30 and 44 years(21.3 percent) and adults between 45 and 64 years were significantly more likely toreport having poor mental health for five or more days than those 65+ years (10.3
percent). Results by gender indicate that females (27.9 percent) were significantly
more likely to report having poor mental health for five or more days than males(18.4 percent). No significant differences were reported by race/ethnicity.
Additionally, 13.2 percent of Texas adults reported having poor mental health for
14 or more days in the past 30 days. No significant differences were reported byage, gender, or race/ethnicity.
The 2020 survey results also indicate that 17.7 percent of Texas adults reported
ever being told by a doctor, nurse, or other health professional that they had adepressive disorder, including depression, major depression, dysthymia, or minor
depression. Females (22.5 percent) were significantly more likely to report everbeing told by a doctor, nurse, or other health professional that they had adepressive disorder than males (12.7 percent), and whites (21.2 percent) weresignificantly more likely to report such than Hispanics (14.8 percent). No significant
differences were reported by age.
35

Texas’ Mental Health Workforce
In addition to patient need, a shortage of providers determines the insufficiency ofthe mental health workforce. The supply of providers can be conceptualized as
being composed of two broad determinants. The first is the entire number ofproviders qualified to serve in mental health, and the second is the number of those
providers committed to providing patient care and the percentage of theirproductive time committed to doing so.113
DSHS uses the population to psychiatrist ratio that is at least 30,000 to 1 or, inareas with high needs, 20,000 to 1 to apply for HPSA’s for mental health through
HRSA. As of June 2020, 236 of the 254 counties (92.9 percent) in Texas werewholly or partially designated as a HPSA for mental health.114 Moreover, as of
September 2019, 173 counties (68.1 percent) in Texas had no psychiatrists.
The state’s mental health workforce shortage is expected to worsen, as theworkforce is aging and many providers are nearing retirement age. At the sametime, educational institutions in the state and the nation are not producing enoughnew graduates to meet projected demand. Given the nationwide mental healthworkforce shortage, it is unlikely that Texas can meet its staffing needs byrecruiting providers from other states.115
DSHS issued a report in 2020 projecting the supply and demand for all physiciansand 35 physician specialties in Texas from 2018 through 2032.116 Statewide resultsfrom this report indicate that there will be an estimated shortage of 1,043 full-time
equivalent psychiatrists by 2032.
In addition to a shortage of providers, other sociodemographic factors contribute to
the state’s inadequate mental health workforce. For example, mental healthproviders are not distributed evenly across the state, resulting in differential accessto care by region, especially in rural areas and along the border. Further, themental health provider workforce does not reflect the state’s growing racial/ethnic
diversity, resulting in the continued need for culturally competent mental healthcare.

Mental Health Workforce by Profession Among
Racial/Ethnic Categories, Texas, 2019
The racial/ethnic distribution of Texas’ mental health workforce differed greatly
from that of the Texas population in 2021. The composition of Texas’ population36

was estimated to be 40.5 percent white, 40.0 percent Hispanic/Latino, 12.0 percent
African American, and 7.5 percent from other races/ethnicities. Yet, whites wereoverrepresented in the majority of mental health professions when compared to the
Texas population. However, over 60 percent of community health workers or
promotores were Hispanic or Latino and 22 percent were African American, whichwere larger proportions than within any other profession. Whites wereoverrepresented in psychiatry by 13 percentage points and people in the “Other”
category by 22 percentage points.

Overview of Mental Health Workforce by Profession
The tables below are based on licensure data that117 DSHS receives annually fromthe respective state licensing board for the following professions: clinical nurse
specialists, community health workers or promotores, licensed baccalaureate social
workers, licensed chemical dependency counselors, licensed clinical social workers,
licensed master social workers, licensed professional counselors, licensed
psychological associates, licensed psychologists, licensed specialists in school
psychology, marriage and family therapists, nurse practitioners, provisionallylicensed psychologists, and psychiatrists.
Counts include only providers who were licensed with their Texas board and actively
working in their profession. Clinical nurse specialists and nurse practitioners include
only those who indicated they were employed in the field of nursing and had a
specialty in psychiatric/mental health. Psychiatrists include only those who
indicated they provided direct patient care. Analyses include all providers for whom
the respective data were available.

37

Table 2. Number of Providers and Population to Provider Ratio of Mental Health
Workforce by Profession, Texas, 2021
Number ofProvidersPopulation to
Provider Ratio

Clinical Nurse Specialists f

152

192,061.0

Community Health Workers or
Promotores

4,515

6,681.9

Licensed Baccalaureate Social Workers

3,623

8,327.1

Licensed Chemical Dependency
Counselors

5,999

5,029.0

Licensed Clinical Social Workers

9,262

3,257.3

Licensed Master Social Workers

11,3102,667.5

Licensed Professional Counselors

23,043

1,309.2

Licensed Psychological Associates

813

37,108.2

Licensed Psychologists

4,955

6,088.6

Licensed Specialists in School Psychology

3,748

8,049.3

Marriage and Family Therapists

2,955

10,209.5

Nurse Practitionersf

1,002

29,135.0

Psychiatrists

2,438

12,374.5

Profession

Using 2021 population projections from the Texas Demographic Center and thetotal number of providers in Texas, licensed professional counselors had the lowest

Nursing professions data for nurse practitioners and clinical nurse specialists were only
available for years 2016-2019. Figures for these professions are from 2014.
f38

population to provider ratio statewide in 2021, followed by licensed master social
workers and licensed clinical social workers.
Table 3. Percentage of Providers and Population to Provider Ratio of Mental Health
Workforce by Profession for Most and Least Populous Counties, Texas, 2021

Percentage
of Providers Five Most
Populous
Counties

Population to
ProviderRatio - Five
Most
Populous
Counties

Percentage
of Providers 249 Least
Populous
Counties

Population to
ProviderRatio - 249
Least
Populous
Counties

Clinical Nurse
Specialistsf

61.8%

138,42738.2%

278,984.9

Community
Health Workers
or Promotores

50.4%

5,916.8

49.6%

6,019.9

Licensed
Baccalaureate
Social Workers

29.6%

12,567.6

70.4%

6,545.1

Licensed
Chemical
Dependency
Counselors

43.6%

5,146.1

56.4%

4,938.3

Licensed ClinicalSocial Workers

58.6%

2,482.9

41.4%

4,352.6

Licensed MasterSocial Workers

54.7%

2,177.5

45.3%

3,259.1

Licensed
ProfessionalCounselors

45.6%

1,283.5

54.4%

1,330.8

Profession

39Percentage
of Providers Five Most
Populous
Counties

Population to
ProviderRatio - Five
Most
Populous
Counties

Percentage
of Providers 249 Least
Populous
Counties

Population to
ProviderRatio - 249
Least
Populous
Counties

Licensed
Psychological
Associates

50.6%

32,779.8

49.4%

41,533.4

Licensed
Psychologists

63.2%

4,300.2

36.8%

9,163.8

LicensedSpecialists in
School
Psychology

48.6%

7,390.3

51.4%

8,673.5

Marriage andFamily Therapists

54.3%

8,394.1

45.7%

12,794.2

Nurse
Practitionersf

56%

23,194.5

44%

36,691.9

Psychiatrists

61.7%

8,963.7

38.3%

17,857.2

Profession

Texas’ mental health workforce is not evenly distributed throughout the state. In
2021, the state’s five most populous counties (Harris, Dallas, Tarrant, Bexar, andTravis) had roughly 44.6 percent of the population. The majority (9 out of 13) ofmental health professions had over half of their workforce in these five counties.

40

Table 4. Growth Trends of Mental Health Workforce by Profession, Texas, 20162021

Profession

Average Annual
Growth Rate Number ofProviders

Average Annual
Growth Rate Population to
Provider Ratio

Clinical Nurse Specialistsf(5%) g

(7.1%)

Community Health Workers or
Promotores

3.2%(1.4%)

Licensed Baccalaureate Social Workers(6.3%)

8.9%

Licensed Chemical Dependency hCounselors

Not available

Not available

Licensed Clinical Social Workers

4.7%(2.9%)

Licensed Master Social Workers

2.8%(1.0%)

Licensed Professional Counselors

4.9%

(3%)

Licensed Psychological Associates(1.9%)

3.7%

Licensed Psychologists

2.4%(0.7%)g

Parentheses in this table indicate a decrease.

hData to calculate annual growth rates of licensed chemical dependency counselors

between 2016 and 2021 were unavailable. However, available data show that the number ofactive licensed chemical dependency counselors in Texas has increased 17.8 percent since2014. Available data also show that, relative to population growth, the size of the licensed
chemical dependency counselor workforce has improved by 8.8 percent over the past five
years.

41

Profession

Average Annual
Growth Rate Number ofProviders

Average Annual
Growth Rate Population to
Provider Ratio

Licensed Specialists in School Psychology

3.1%(1.4%)

Marriage and Family Therapists

1.7%(0.05%)

Nurse Practitionersf

21.6%

16.0%

Psychiatrists

2.9%(1.2%)

Among the 13 mental health professions for whom annual growth rates between
2016 and 2021 were available, nine professions had an increase in the averageannual growth rate for the number of providers in Texas. When considering
population growth, only three of these 13 mental health professions had an
improvement in the size of the workforce over these five years.

42

Table 5. Number of Counties with No Providers of Mental Health Workforce byProfession, Texas, 2016-2021
Profession

2016

2021

Clinical Nurse Specialistsf

208

218

Community Health Workers or
Promotores

131

112

Licensed Baccalaureate Social Workers

52

63

Licensed Chemical Dependency
Counselors

82

78

Licensed Clinical Social Workers

114

91

Licensed Master Social Workers

79

74

Licensed Professional Counselors

46

37

Licensed Psychological Associates

153

168

Licensed Psychologists

143

147

Licensed Specialists in School Psychology

166

105

Marriage and Family Therapists

132

112

Nurse Practitionersf

206

185

Psychiatrists

173

168

Many counties in Texas do not have any providers for at least one mental healthprofession. The number of counties in the state with no providers increased for four
mental health professions between 2016 and 2021, while the number of counties inthe state with no providers decreased for nine mental health professions.

43

Table 6. Percentage of Mental Health Workforce by Profession Eligible for
Retirement in 10 Years, Texas, 2021
Professioni

56-65 Years

Over 65 Years

Total i

Clinical Nurse Specialistsf

32.9%

59.9%

92.8%

Community Health Workers
or Promotores

10.8%

4.9%

15.7%

Licensed Baccalaureate
Social Workers

25.9%

11.6%

37.5%

Licensed Chemical
Dependency Counselors

27.3%

18.9%

46.2%

Licensed Clinical Social
Workers

16.9%

16.4%

33.3%

Licensed Master Social
Workers

10.3%

5.9%

16.2%

Licensed ProfessionalCounselors

17.2%

16.4%

33.6%

Licensed Psychological
Associates

24.1%

24.4%

48.5%

Licensed Psychologists

17.2%

25.6%

42.8%

Licensed Specialists in
School Psychology

10.9%

11.6%

22.5%

Marriage and Family
Therapists

18.6%

29.5%

48.1%

Nurse Practitionersf

14.5%

5.7%

20.2%

Psychiatrists

21.6%

24.4%

46%

Calculations in the total column are based on unrounded numbers.

44

Policy Recommendations for the Legislature,
the Governor, and Executive Branch Agencies
Support efforts by school districts to increase access to mental healthservices for students.
Increasing the number of counselors and psychologists employed by school districtsin the state is one way that school districts may increase access to mental healthservices for students. Generally, the recommended student to provider ratio differs
based on the profession. For example:●●

The American School Counselor Association recommends a student to school
counselor ratio of 250 to 1.118
The National Association of School Psychologists recommends a student toschool psychologist ratio between 500 to 1 and 700 to 1.119

According to the Texas Education Agency, there were 13,864 full-time equivalentcounselors and 2,089 full-time equivalent licensed specialists in school psychology
or psychologists employed by school districts in Texas during the 2020-2021 school
year.120 Based on the statewide enrollment of 5,371,586 students, there was astudent to counselor ratio of 387.4 to 1 and a student to licensed specialist in
school psychology or psychologist ratio of 2,570.4 to 1 for the 2020-2021 school
year.121
As the statewide ratios for counselors and licensed specialists in school psychology
or psychologists employed by school districts exceed the ratio recommended by therespective professional association listed above, it is important that school districts
consider increasing the number of counselors and psychologists that they employ.
Moreover, additional providers employed by school districts would better ensurethat students have access to mental health services in the school setting.
Another way that school districts in the state may increase access to mental healthservices for students is to partner with community mental health centers. Currently,
school districts are not required to provide mental health services to students or topartner with community mental health centers in providing such services. As not all
school districts have prioritized providing mental health services, many students
throughout the state may not have access to mental health services in the school
setting.

45

Due to the challenge of providing mental health services and the limited resourcesof many school districts, particularly in rural areas, it is important that school
districts not be burdened with creating their own infrastructure for providing mental
health services. In addition, solutions should be developed that leverage existing
services. As community mental health centers already have the staff, training, andexperience necessary to help students, partnering with them would allow school
districts to take advantage of existing services in a cost-effective manner.
Furthermore, it may not be necessary for every school district to have a full-timemental health provider. Partnering with community mental health centers would
allow school districts, especially those that do not provide mental health services, toincrease access to cost-effective mental health services for students.
Post-secondary students face their own challenges on campus. A 2021 study
reported that suicide is the third leading cause of death in students and that up to
44 percent of college students reported having symptoms of depression andanxiety.122 Additionally, of those who have been diagnosed with a mental healthdisorder, most (75 percent) have their first episode by age 24. Texas A&M
University conducted a study in 2020 of the effects of COVID-19 on college
students’ mental health.123 They found that 71 percent of undergraduate students
reported experiencing increased stress and anxiety due to the COVID-19 pandemic.
Of those students, 91 percent were concerned about the health of their loved ones
and themselves, 89 percent experienced difficulty concentrating, 86 percent
reported disruptions to sleeping patterns, 86 percent reported decreased social
interactions due to physical distancing, and 82 percent reported increased concerns
on academic performance. Nationally and statewide, college and university students
are facing complex mental health issues.

Continue outreach efforts to de-stigmatize behavioral health, and forresources for mental health providers for students.
According to the 2019 Texas Youth Risk Behavioral Survey results, 10 percent ofTexas high school students attempted suicide, and 38.3 percent felt sad or hopelessfor two weeks in a row within the year leading up to the survey.124 The lack ofoutreach, resources, and efforts to normalize mental health in schools has led tothe isolation of students struggling with mental health issues. In addition to therecommendation above, schools should create curriculum on mental health topics
and incorporate this knowledge into classes, campaigns, and assemblies that invite

46

experts on relevant mental health topics. The de-stigmatization of mental healthchallenges will decrease the barriers to improving mental health for students.
Continue to support the work of the Texas Child Mental Health Care
Consortium (TCMHCC).
Senate Bill 11, 86th Legislature, Regular Session, 2019, established the TCMHCC.125
Members of the consortium include 13 health-related institutions of higher
education, HHSC, the Texas Higher Education Coordinating Board, and three
nonprofit organizations that focus on mental health care.126 These nonprofit
organizations currently include the Meadows Mental Health Policy Institute, the
Hogg Foundation for Mental Health, and the Texas Council of Community HealthCenters.127 The consortium is governed by an executive committee.128
The purpose of the consortium is to:●●

Leverage the expertise and capacity of the 13 health-related institutions ofhigher education to address urgent mental health challenges and improve themental health care system in the state in relation to children andadolescents; andEnhance the state's ability to address the mental health care needs ofchildren and adolescents through collaboration of the 13 health-related
institutions of higher education.129

The consortium is tasked with the following initiatives:●●

Establish a network of comprehensive child psychiatry access centers; andEstablish or expand telemedicine or telehealth programs to identify andassess behavioral health needs and provide access to mental health careservices.

In addition, the executive committee is authorized to provide funding to any of the
13 health-related institutions of higher education for the purpose of expanding thestate’s child mental health workforce.130 Such funding may be provided to expand
the child psychiatry workforce and/or to add a child and adolescent psychiatry
fellowship.
The 2022-23 General Appropriations Act, Senate Bill 1, 87th Legislature, Regular
Session, 2021, increased the TCMHCC funding, which allocated $19.5 million infunds for the TCMHCC to support the Child Psychiatry Access Network and theTexas Child Health Access Through Telemedicine initiatives.13147

As the initiatives of the TCMHCC have the ability to improve access to mental healthservices for children and adolescents throughout the state, it is imperative that thework of the consortium continue to be supported. Such support will better ensurethat the state is able to address the mental health care needs of children andadolescents.
Continue to support the work of the Statewide Behavioral Health
Coordinating Council.
The 2016-17 General Appropriations Act, House Bill 1, 84th Legislature, Regular
Session, 2015 (Article IX, Section 10.04), established the Statewide Behavioral
Health Coordinating Council.132 Members of the council include representatives ofstate agencies and institutions of higher education that receive state funding toprovide behavioral health services. The purpose of the council is to ensure a
strategic statewide approach to behavioral health services.133 The council isprimarily charged with the following duties:●●●

Develop and monitor the implementation of a five-year statewide behavioral
health strategic plan;
Develop a biennial coordinated statewide behavioral health expenditureproposal; andAnnually publish an updated inventory of behavioral health programs andservices that are funded by the state that includes a description of how those
programs and services further the purpose of the statewide behavioral healthstrategic plan.

House Bill 4074, 87th Legislature, Regular Session, 2021, called for the assemblingof a subcommittee on suicide prevention and the inclusion of a suicide prevention
plan in the Statewide Behavioral Health Strategic Plan.134
In the Texas Statewide Behavioral Health Strategic Plan, Fiscal Years 2017-2021,
the behavioral health workforce shortage was identified as one of the gaps in thestate’s behavioral health system.135 As the Statewide Behavioral Health
Coordinating Council is addressing the state’s mental health workforce shortage, it
is imperative that the work of the council continue to be supported. Such support
will allow the council to further develop strategies that may improve access to thestate’s behavioral health system.
Support efforts to increase the funding and stipends available to studentsof the mental health professions as they complete their education andtraining.
48

Completing the education and training required to become a mental health provider
is a timely and expensive process. To lessen the financial burden faced by studentsof the mental health professions, consideration should be given to expanding thefunding and stipends available to them as they complete their education andtraining. By expanding such funding and stipends, more individuals may be
incentivized to select a mental health profession, likely leading to an increase in thestate’s mental health workforce.
Support the expansion of the Loan Repayment Program for Mental HealthProfessionals.
To recruit individuals to the state’s mental health workforce and to retain theexisting mental health workforce, it is important to expand practice incentives formental health providers. One practice incentive that could be expanded is the Loan
Repayment Program for Mental Health Professionals that is administered by the
Texas Higher Education Coordinating Board.136 The eligibility criteria for thisprogram could be expanded to include additional practice specialties, practiceareas, and/or types of recipients that receive care. For example:●●●

The practice specialties of mental health providers could be expanded toinclude licensed psychological associates, licensed specialists in school
psychology, provisionally licensed psychologists, licensed baccalaureatesocial workers, licensed master social workers, and/or community healthworkers or promotores.137
The practice location of mental health providers could be expanded to include
areas not designated by HRSA as HPSA’s for mental health.138
The types of recipients that receive care from mental health providers could
be expanded to include individuals who receive mental health services but
are not: Enrolled in Medicaid; Enrolled in CHIP;
 Committed to a secure correctional facility operated by or under contract
with the Texas Juvenile Justice Department; and/or
 Confined in a secure correctional facility operated by or under contract
with any division of the Texas Department of Criminal Justice.

The funding for the Loan Repayment Program for Mental Health Professionals could
also be expanded. Doing so could improve the efficacy of the program, as new
program participants may be able to enroll in the program sooner and the overall
number of mental health providers participating in the program may increase.
49

By expanding the eligibility criteria and/or funding for the Loan Repayment Programfor Mental Health Professionals, the ability to recruit and retain mental healthproviders would be strengthened. Moreover, given that the state’s mental healthworkforce is aging and many providers are nearing retirement age, it is imperativethat measures are taken to encourage and incentivize individuals to enter a mental
health profession.
Support expanding the reciprocity of licenses for behavioral healthproviders between states.
The process of obtaining a license in a new state can be difficult for licensed mental
health providers who are transitioning from one state to another. This process canrequire a considerable amount of time to complete and be cumbersome to navigate
due to states having different requirements. To ease the process for licensed
mental health providers seeking to relocate to Texas and become licensed by thestate, it is important to expand the reciprocity standards between states. Doing so
may lead to an increase in the state’s mental health workforce and, thus, greater
access to mental health services in the state.
Support the increase of reimbursement rates for behavioral healthproviders.
The current payment system is a key barrier that affects the recruitment andretention of mental health providers in the state. As the current payment systemfails to adequately reimburse mental health providers, many providers are not able
to sustain providing mental health services and/or expand their capacity of doing
so. To lessen this barrier, consideration should be given to increasing
reimbursement rates for mental health providers. By increasing such rates, thestate would strengthen its ability to recruit and retain mental health providers, aswell as better ensure access to mental health services throughout the state.
Increase the amount of education on suicide prevention for students
within health care fields.
Often times, health care providers and first responders are the personnel thatpatients first see before they see a psychiatrist, psychologist, social worker,
counselor, or other behavioral health provider. Providing more education on suicide
prevention, depression, and anxiety for primary care providers, nurses, and first
responders would allow for more detection of these conditions and for patients toreceive the care needed. Additional options could include questions between patientand provider at annual physicals or routine appointments and additional intake
50forms prior to an appointment to detect issues before they increase in severity forthe patient. HRSA has allocated federal funding toward colleges and universities
that educate the medical health care workforce to more holistically educate themon the diverse needs of each patient.139 The continuation and expansion of thesetypes of resources would allow the Texas health care workforce to detect and treat
mental health issues before they become exacerbated.
Monitor the effects of the COVID-19 pandemic on behavioral health inTexas.
Texans’ mental and behavioral health faced tremendous challenges around accessto care before the COVID-19 pandemic. Overall, Texans had a greater percentageof people who faced symptoms of anxiety disorder or depressive disorder (34.5
percent) than nationally (31.5 percent).140 Younger age groups had more symptomsof anxiety and depression, 48.4 percent of the 18-29 age category reportinganxiety and depression symptoms, while 17.8 percent of people over 80 reporting
symptoms. Nationally, 14.5 percent (40.3 million) of people aged 12 and over faced
substance abuse disorder in 2020.104 HHSC estimates that 11.3 million Texans areliving with substance use disorder.141 There is a general gap in data surrounding
Texans facing substance use disorder during the COVID-19 pandemic. During 2020,
Texas fell below national rates of drug overdose deaths per 100,000 people at 14.3
versus 28.3, respectively.142 Expanding the processes, methods, and technology fordata collection would improve our insights into Texans’ mental and behavioral
health trends. It is imperative that this work obtains support, as statistics often
contribute to how compelling research is communicated to institutions andlegislative entities, and more mental and behavioral health services would be able
to reach Texans.
Having access to data during different stages of the COVID-19 pandemic has
granted Texas mental and behavioral health care institutions the ability to adapt toneeds within their communities. During the onset of the COVID-19 pandemic, HHSC
launched a mental health support line in an effort to help Texans gain access tomental health services.143 The COVID-19 Mental Health Support Line (833-9861919) has provided information on the ongoing COVID-19 pandemic, direct accessto local mental and behavioral health authorities, statewide testing and vaccine
information, and referrals to resources through 2-1-1 (essential services provided
through United Way). In 2022, HHSC launched a $23.3 million substance use
prevention awareness campaign with the goal of reducing drug use among Texas
youth and families. Without data on the continuing effects of the COVID-19
pandemic on the mental and behavioral health of Texans, services like these would
51

not exist. The data, accuracy, methods, procedures, and reports could better serve
health care institutions and Texans with investment for further examination.
Continue to support the investment in recruitment and retention of themental and behavioral health care workforce.
The mental and behavioral health care workforce shortage has persisted in Texas
since before the COVID-19 pandemic. The Statewide Behavioral Health
Coordinating Council’s December 2020 report states that workforce shortage has
been a decades-long issue.144 The plan details the short, mid, and long-term action
items surrounding the retention and recruitment of behavioral health careproviders. The Statewide Behavioral Health Coordinating Council formed a
subcommittee in 2019 to develop a plan for increasing and improving the workforce
in Texas to better serve people with mental and substance use issues.
Texas faces behavioral workforce shortages in a variety of professions within thefield. When speaking about psychiatrists specifically, demand will continue tooutpace supply by almost two percentage points from the years 2017-2030.116
HRSA reports that Texas contains 476 mental HPSA’s in the state, meaning thoseareas contain a higher ratio than 30,000 to one health professional per region.145
With the unknown, emerging, and persistent mental and behavioral health issues
Texans are facing, the mental and behavioral health care workforce should be
expanded and supported to the fullest extent.
Allocate funds toward the implementation of the 988 Suicide Prevention
Lifeline.
In February 2021, HHSC received a $180,000 grant from Vibrant Emotional Healthto support the new 988 Suicide Prevention Lifeline.146 The lifeline will make it easierfor people in crisis to reach someone within their local community for mental healthsupport and resources. In July 2022, the 988 Suicide Prevention Lifeline replaced
the National Suicide Prevention Lifeline, formerly known as 1-800-273-8255(TALK).
The grant funds will help existent call centers within Texas prepare for
infrastructure needs, additional callers, purchase headsets, phones, and computers,
train and educate staff, and collect data. Increasing the funding of this endeavor
will support launch efforts and continuation.

52

6. Teleservices and Technology
This section discusses the definition, use, and benefits of teleservices in Texas.
Additionally, it includes how teleservices have been expanded due to the COVID-19
pandemic and how teleservices will continue to be used and changed postpandemic.

Defining Teleservices
Federal Medicaid defines telemedicine as an alternative to traditional care in whicha patient and provider meet in real time, using both audio and video equipment, at
separate sites.147 According to the Texas Occupations Code, telemedicine isrequired to fulfill the same standard of care that would be applied in an in-person
setting.148
Telemedicine and telehealth are often used as interchangeable terms. Telemedicine
is defined as “the remote delivery of health care services and clinical information
using telecommunications technology” while telehealth is “used to describe
diagnosis and management, education, and other fields of health care.”149,150 The
term “teleservices” will be used to include both “telemedicine” and “telehealth” forthe remainder of this section. For information and data relating specifically to“telemedicine” or “telehealth,” those terms will be applied.

Use of Teleservices in Texas
H.B. 2386, 75th Legislature, Regular Session, 1997 allowed medical providers to be
reimbursed for telemedicine services.151 In 2016, the e-Health Advisory Committee
was established to advise HHSC on “the development, use, and long-range plans
for telemedicine, telehealth, and home telemonitoring services.”152 The mostcommon users of these teleservices are those diagnosed with Attention-Deficit
Hyperactivity Disorder (ADHD), followed by schizophrenia, schizoaffective disorder,
and bipolar disorder.151
Texas Medicaid users were included among those for whom teleservices wereavailable. While this has been the case for over 20 years, it is only recently that theservice has begun to see wider spread adoption. From 2012 to 2018, there has
been a 119 percent increase in use of teleservices compared to a 338 percent inoverall use of providers offering teleservices. From fiscal year 2018 to 2019, the53

utilization of telemedicine services increased by 19 percent, telehealth services
increased by 37 percent, and telemonitoring services increased by 23 percent.151

COVID-19 and the Expansion of Teleservices
On January 31, 2020, a national Public Health Emergency was declared due to the2019 novel Coronavirus.153 On March 17, 2020, Governor Greg Abbott announced
an emergency rule to “allow telemedicine visits for patients with state-regulatedplans to be paid the same as in-office visits for insurance purposes.”154 On
September 25, 2020, this rule was extended through the end of 2020 and
expanded to include other major health insurers in Texas, ensuring that Texans
could continue utilizing telehealth during the pandemic.155
In 2021, several bills passed and became effective that supported reimbursement
to providers for teleservices. These include, H.B. 4, 87th Legislature, Regular
Session, 2021: reimbursement for health programs using telecommunications;156
S.B. 228, 87th Legislature, Regular Session, 2021: relating to the reimbursement of“claims by certain health benefit plan issuers for telemedicine services andtelehealth services;”157 and S.B. 434, 87th Legislature, Regular Session, 2021:
pertaining to the delivery of “certain health, mental health, and educational services
in this state” through telecommunication or information technology.158 Other bills
relating to teleservices were also introduced as a result of the pandemic, such as
S.B. 488, 87th Legislature, Regular Session, 2021 addressing teledentistry
services.159
Due to the need and the opportunity to take advantage of teleservices, the numberof teleservices increased drastically after the COVID-19 pandemic began. There wasa 2,840 percent increase in teleservices provided to Texas Medicaid clients in thefirst few months of 2020.160
The data in Figure 1 below includes the number of teleservices provided across all
Medicaid and CHIP programs in Texas. In February of 2020, right before the
COVID-19 virus was detected in Texas, the number of monthly teleservices wasless than 30,000 statewide. A Public Health Disaster Declaration was issued in
Texas in March of 2020 and subsequently the number of monthly teleservices
drastically increased to over 850,000 in April 2020. While teleservices havedecreased from this peak in April 2020, they remain high.

54

Figure 1: Number of Teleservices per Month Under Medicaid and CHIP161
900,000

859,511763,843

800,000
700,000

719,324

675,340

600,000

694,077

650,253

500,000

643,019594,298474,736438,929400,000
368,263

300,000

199,325

200,000

Aug-21

Jul-21

Jun-21

May-21

Apr-21

Mar-21

Feb-21

Jan-21

Dec-20Nov-20

Oct-20

Sep-20Aug-20Jul-20Jun-20May-20

Apr-20Mar-20Feb-20Jan-2029,242
Dec-19

Nov-19Oct-19100,000
28,0380

Benefits of Teleservices
The benefits of teleservices are widespread. For clients of Texas Medicaid who areblind or have a disability, utilizing teleservices led to less use of inpatient,outpatient, and emergency department services. Overall, the use of teleservices forthese clients cost $502 less per client per month than using in-person services. It
was also found that overall medical spending for this population increased,suggesting that teleservices are fulfilling previously unmet needs.151
Rural areas in Texas also benefit greatly from teleservices. Rural communities often
use teleservices to “augment limited provider resources” caused by losing andhaving difficulties recruiting health providers.160 Teleservices also decrease thenumber of no-show patients because factors like childcare, transportation, andparking are less of an issue.160 Health providers, through teleservices, are also able
to “assess a patient’s living environment” which can be indicative of certain healthoutcomes.160
A study on medically complex children (children with one or more chronic conditions
that require continuous medical attention) showed that clinical outcomes favored
those using teleservices by 66 to 98 percent, reducing hospital and pediatricintensive care unit admissions. Teleservices also reduced total health system costsby 91 percent per child, per year.162
55

Access to Teleservices
In order to partake in offered teleservices, individuals must have access tobroadband or highspeed internet, access to technologies that can function as audio
and visual tools, and the knowledge to work these technologies.160,163 Those without
access to these three elements are often the socioeconomically disadvantaged andthose living in rural areas.

Access in Rural Counties
The success of teleservices is dependent on the patient’s access to teleservices andon the provider’s ability to deliver teleservices. In December 2020, 96 percent ofhouseholds in Texas had the option to connect to broadband internet, leaving
316,700 households without that ability.160 Of those remaining households, 89
percent were considered rural.160 Without widespread access to broadband, rural
households, specifically those who are socioeconomically disadvantaged, risk being“left further behind with the increased implementation of telehealth,” due to theirlack of access to necessary technologies.163 H.B. 5, 87th Legislature, Regular
Session, 2021 created “the Broadband Development Office which will award grants
and loans and provide other incentives in the interest of expanding access tobroadband in underserved areas,” enabling rural areas to gain much needed accessto telemedicine.164
House Bill 76, 87th Legislature, 3rd Special Session was introduced on September
16, 2021, related to a pilot project to provide emergency telemedicine services andtelehealth services in rural areas. The bill ultimately did not pass but the proposed
program would connect emergency providers in rural areas to a call center thatwould help determine where the patient needs to go and help the emergency
providers treat them, prehospital, in the field.165,166 Even with these kinds ofprograms being developed in rural areas, the majority of teleservice providers“continue to be located in large Metropolitan Statistical Areas, such as Dallas-Fort
Worth-Arlington, San Antonio, and Houston-The Woodlands-Sugar Land.”151

Providers’ Ability to Deliver Teleservices
Another limitation of teleservices is the ability for a provider to offer those services
under existing legislation or regulation. In March of 2020, the Texas Medical
Association released a document outlining the rules and regulations on thetechnology, billing, and policies surrounding telemedicine due to the COVID-19
pandemic.167

56

If a patient travels or moves out of state, they cannot continue seeing theirprovider, even through teleservices, if their provider is not licensed in the state of
their physical location. The Interstate Medical Licensure Compact (IMLC) allows
doctors to become licensed in multiple states and is one way a provider cancontinue giving care to patients who have moved out of their original state.168 The
IMLC was launched even before the start of the COVID-19 pandemic, but manystates do not participate.169 Texas is still in the process of implementing the IMLC
for physicians.168
Before the pandemic, Health Insurance Portability and Accountability Act (HIPAA)
privacy standards disallowed providers from utilizing more user-friendly platforms
to conduct teleservices. After emergency protocols were put into place during
COVID-19, HIPAA compliance was relaxed and many providers began using
platforms like Skype and FaceTime. As pandemic legislation expires, providers must
use more HIPAA-compliant platforms that are often less accessible to patients,
making it more difficult for these providers to deliver teleservices.169

Teleservices Post-COVID-19
Two years after the Public Health Emergency was declared, states are beginning toretighten their rules on teleservices.169 However, the COVID-19 pandemic forced
many physicians, who had previously never provided teleservices, to begin shifting
their practice to become more teleservice focused. Because of this, “nearly 11,000
additional providers served Medicaid beneficiaries using teleservices, with about
5,000 of this group providing a teleservice to a rural resident.”160 This increased thenumber of physicians experienced in teleservices and increased health care services
in rural areas. Throughout 2022, HHSC will evaluate the feasibility of continuing
certain teleservices that were available under Medicaid and CHIP during the Public
Health Emergency.170
Legislation was introduced to continue the expansion of teleservices. S.B. 434, 87th
Legislature, Regular Session, 2021 as discussed in the “Expansion of Telemedicine”
section above requires the executive commissioner to adopt certain rules,“including rules governing when the delivery of service coordination benefits using
telecommunications or information technology is appropriate.”158 In Section
403.153 of Senate Bill 434, under “Use of Telecommunication Technology,” license
holders will be able to “provide a service solely through the use of an interactive
audiovisual communication system, whether real-time or two-way, including asmartphone.” The bill did not pass, but looking towards future sessions, it ispossible that legislation affecting telehealth services will continue to be filed.
57

Ultimately, whether teleservices will continue to be provided and used will depend
on Medicare and private insurance companies continuing to cover them. If Congress
does not extend Medicare’s teleservices coverage, Medicare could begin excluding
teleservices to clients and taking away reimbursement that has helped thousands ofTexans throughout the public health emergency.160 HHSC’s stakeholders have“expressed interest in making COVID-19 telemedicine, telehealth, and telephonicflexibilities permanent benefits of Texas Medicaid.”151

Policy Recommendations for the Legislature,
the Governor, and Executive Branch Agencies
Continue to expand the Statewide Health Information Exchange andincentivize its use among third party teleservices agencies.
Many Texans choose third party teleservices agencies when seeking care. Health
Information Exchange programs are utilized by health care providers and enable
better health care coordination, better quality of care, and can also keep healthcare costs down.171 The Health Information Technology for Economic and Clinical
Health Act was enacted in 2009 to incentivize the promotion of health information
technology and exchange.172 The Texas Health Information Exchange
Implementation Advanced Planning Document defines the funding opportunities for
eligible health professionals who adopt health information exchange systems.173
These funding mechanisms are supported by Centers for Medicare and Medicaid
Services and may not always reach third party teleservice providers. By connecting
third party teleservice providers with patients’ primary care physicians throughHealth Information Exchange programs, the state is ensuring that patients arereceiving quality, safe, and effective care as well as improving public healthreporting and monitoring.171
Encourage state, federal, and private health insurance organizations topromote their teleservice benefits.
Teleservices provide an array of benefits for patients, including the elimination oftransportation costs and scheduling flexibility.167 Benefits also extend to providers
and organizations who can provide more cost-effective care169 to a larger
population, specifically in rural areas.166 Many state, federal, and private healthinsurance organizations have policies regarding teleservices, including thereimbursement and steps for utilization. Insurance consumers would benefit fromlearning and understanding the services they already have access to.
58

Support new and innovative ways to get teleservices to rural communities.
Getting teleservices to rural communities is essential in ensuring that thesecommunities have access to health care. With 4 percent, or more than 300,000
households, unable to access broadband internet across Texas,160 ruralcommunities need options for teleservices that don’t require this broadband access.
One example is organizations that have provided direct-to-consumer care using
telemedicine kiosks placed in pharmacies in rural areas. These kiosk systems havebeen observed to increase health care access without requiring an internet
connection at home.174 Community Health Workers could also be considered to help
bridge the gap in knowledge needed to access teleservices, especially for theelderly population.
Investigate the training requirements for teleservice providers todetermine if adequate training is being conducted at health institutions.
As the number of teleservices provided each month remains high, more than ten
times the number of teleservices provided to Medicaid and CHIP recipients in
February 2020,161 the need for health care providers to be able to deliver these
services is also high. Especially at the beginning of the COVID-19 pandemic,
physicians and other health care providers began providing care throughteleservices, often for the first time. Providers should be trained to deliver
teleservices through their practice to ensure that quality of care is being met.

59

7. List of Acronyms
Acronym

Full Name

ACA

Affordable Care Act

CHIP

Children’s Health Insurance Program

COVID-19

Coronavirus Disease 2019

DSHS

Department of State Health Services

DSRIP

Delivery System Reform Incentive Payment

EMS

Emergency Medical Services

FPL

Federal Poverty Level

HHSC

Health and Human Services Commission

HIPAA

Health Insurance Portability and Accountability Act

HPSA

Health Professional Shortage Area

HRSA

Health Resource Services Administration

IMLC

Interstate Medical Licensure Compact

STAR

State of Texas Access Reform

STAR+PLUS

State of Texas Access Reform PlusTCMHCC

Texas Child Mental Health Care Consortium

60

Acronym
TIPPS

Full Name
Texas Incentives for Physician and Professional Service

61Appendix A. Statewide Health Coordinating Council
Roster
Gubernatorial Appointees

Role

Elizabeth Protas, P.T., Ph.D.
Chair, League City

Public Member

Kimberly Haynes, D.M.D, C.A.G.S., F.I.D.I.A.
Leander

Health Care Professional

Emily Hunt, D.N.P
Houston

Hospital Representative

Carol Boswell, Ed.D., R.N., C.N.E., A.N.E.F.,
F.A.A.N.
Andrews

University Representative

Bharath Thankavel, M.D.
DallasHMO Representative

Chelsea Elliott
AustinPublic Member

Cheryl Sparks, Ed.D.
Big Spring

Community College Representative

Melinda Rodriguez, P.T., D.P.T.
San Antonio

Health Care Professional

Tamara Rhodes, M.S.
Amarillo

Nurse Representative

D. Bailey Wynne, M.H.A., R.Ph., C.H.E.S.
DallasPublic Member

Doris Jackson, D.H.A.
Pearland

University Representative

Ken Holland
Huntsville

Public Member

Yasser Zeid, M.D.
Tyler

Health Care Professional

State Agency Members

Representing

Jimmy Blanton, M.P.Aff.
AustinTexas Health and Human Services
Commission

Courtney Harvey, Ph.D.
AustinTexas Health and Human Services
Commission

62

Aelia Akhtar
AustinTexas Department of State HealthServices

Elizabeth Mayer, M.P.Aff.
AustinTexas Higher Education Coordinating
Board

63

8. References
1. Gulliford M, Figueroa-Munoz J, Morgan M, et al. What does “access to healthcare” mean? J Health Serv Res Policy. 2002;7(3):186-188.
2. Pandhi N, DeVoe JE, Schumacher JR, et al. Number of First-Contact Access
Components Required to Improve Preventive Service Receipt in Primary Care
Homes. J Gen Intern Med. 2012;27(6):677-684. doi:10.1007/s11606-0111955-7
3. Shi L, Lebrun-Harris LA, Daly CA, et al. Reducing Disparities in Access to Primary
Care and Patient Satisfaction with Care: The Role of Health Centers. J HealthCare Poor Underserved. 2013;24(1):56-66.
4. Leveque JF, Harris MF, Russell G. Patient-centred access to health care:
conceptualising access at the interface of health systems and populations. Int J
Equity Health. 2013;12(18). Accessed November 4, 2021.
https://link.springer.com/article/10.1186/1475-9276-12-18
5. Kullgren JT, McLaughlin CG, Mitra N, Armstrong K. Nonfinancial Barriers andAccess to Care for U.S. Adults. Health Serv Res. 2012;47(1):462-485.
doi:10.1111/j.1475-6773.2011.01308.x
6. Neuhausen K, Grumbach K, Bazemore A, Phillips RL. Integrating Community
Health Centers Into Organized Delivery Systems Can Improve Access To
Subspecialty Care. Health Aff (Millwood). 2012;31(8):1708-1716.
doi:10.1377/hlthaff.2011.1261
7. Au M, Taylor EF, Gold M. Improving Access to Language Services in Health Care:
A Look at National and State Efforts. Mathematica Policy Research, Inc.; 2009.
8. Gessert C, Waring S, Bailey-Davis L, Conway P. Rural definition of health: asystematic literature review. BMC Public Health. 2015;15(378). Accessed
November 4, 2021. https://link.springer.com/article/10.1186/s12889-0151658-9
9. Kenney GM, McMorrow S, Zuckerman S, Goin DE. A Decade Of Health Care
Access Declines For Adults Holds Implications For Changes In The Affordable
Care Act. Health Aff (Millwood). 2012;31(5):899-908.
10.Agency for Healthcare Quality Research. 2019 National Healthcare Quality andDisparities Report. US Department of Health and Human Services; 2020.
Accessed December 29, 2021.
https://www.ahrq.gov/research/findings/nhqrdr/nhqdr19/index.html
11.Flores G, Lin H. Trends in racial/ethnic disparities in medical and oral health,access to care, and use of services in US children: has anything changed over
the years? Int J Equity Health. 2013;12(10). doi:10.1186/1475-9276-12-10
64

12.Radley DC, Schoen C. Geographic Variation in Access to Care — The Relationshipwith Quality. N Engl J Med. 2012;367(1):3-6. doi:10.1056/NEJMp1204516
13.Jan 21 ADP, 2021. The Coverage Gap: Uninsured Poor Adults in States that Do
Not Expand Medicaid. KFF. Published January 21, 2021. Accessed November 4,2021. https://www.kff.org/medicaid/issue-brief/the-coverage-gap-uninsuredpoor-adults-in-states-that-do-not-expand-medicaid/
14.U.S. Census Bureau. 2016-2020 American Community Survey; Public Use Micro
Data Sample (Texas-Specific).
15.Texas Behavioral Risk Factor Surveillance System 2020.
16.2020 5-Year American Community Survey (Texas-Specific Samples). U.S.
Census Bureau
17.Everyone Included: Social Impact of COVID-19. United Nations Department of
Economic and Social Affairs. Accessed January 20, 2022.
https://www.un.org/development/desa/dspd/everyone-included-covid-19.html
18.Reduced Access to Care During COVID-19 | Data | Centers for Disease Control
and Prevention. Centers for Disease Control and Prevention. Published August 6,
2021. Accessed January 20, 2022. https://data.cdc.gov/NCHS/Reduced-Accessto-Care-During-COVID-19/th9n-ghnr
19.Dorn S. The COVID-19 Pandemic and Resulting Economic Crash Have Caused
the Greatest Health Insurance Losses in American History. Families USA.
Published July 13, 2020. Accessed January 20, 2022.
https://familiesusa.org/resources/the-covid-19-pandemic-and-resultingeconomic-crash-have-caused-the-greatest-health-insurance-losses-in-americanhistory/
20.Garfield R, Claxton G, Damico A, Levitt L. Eligibility for ACA Health Coverage
Following Job Loss - Appendix. Kaiser Family Foundation. Published May 13,
2020. Accessed January 20, 2022. https://www.kff.org/report-section/eligibilityfor-aca-health-coverage-following-job-loss-appendix/
21.Sparber MM and S. As Texas expands COVID-19 vaccination eligibility, racialdisparities persist among Black, Hispanic residents. The Texas Tribune.
https://www.texastribune.org/2021/03/19/texas-vaccine-race-disparities/.
Published March 19, 2021. Accessed January 20, 2022.
22.Ndugga N, Hill L, Artiga S, Sweta H. Latest Data on COVID-19 Vaccinations byRace/Ethnicity. Kaiser Family Foundation. Published January 12, 2022. Accessed
January 20, 2022. https://www.kff.org/coronavirus-covid-19/issue-brief/latestdata-on-covid-19-vaccinations-by-race-ethnicity/
23.CDC. COVID Data Tracker. Centers for Disease Control and Prevention.
Published January 1, 2022. Accessed September 29, 2022.
https://covid.cdc.gov/covid-data-tracker
65

24.Texas Health Professions Resource Center Physician 2021 Data.
25.Paradise J, Garfield R. What is Medicaid’s Impact on Access to Care, Health
Outcomes, and Quality of Care? Setting the Record Straight on the Evidence Issue Brief. Kaiser Family Foundation. Published August 2, 2013. Accessed
January 21, 2022. https://www.kff.org/report-section/what-is-medicaidsimpact-on-access-to-care-health-outcomes-and-quality-of-care-setting-therecord-straight-on-the-evidence-issue-brief/
26.Health Insurance Coverage of the Total Population (CPS). Kaiser Family
Foundation. Published September 21, 2021. Accessed January 21, 2022.
https://www.kff.org/other/state-indicator/health-insurance-coverage-of-thetotal-population-cps/
27.Green LV, Savin S, Lu Y. Primary Care Physician Shortages Could Be EliminatedThrough Use Of Teams, Nonphysicians, And Electronic Communication. Health
Aff (Millwood). 2013;32(1). Accessed January 21, 2022.
https://doi.org/10.1377/hlthaff.2012.1086
28.Harvard T.H. Chan School of Public Health, Robert Wood Johnson Foundation,
National Public Radio. Patients’ Perspectives on Health Care in the United States:
Texas. Published online 2016.
29.DSRIP Transition | Texas Health and Human Services. Accessed January 20,
2022. https://www.hhs.texas.gov/regulations/policies-rules/waivers/medicaid1115-waiver/dsrip-transition
30.Texas Incentives for Physicians and Professional Services (TIPPS) Program |Texas Health and Human Services. Accessed January 20, 2022.
https://www.hhs.texas.gov/services/health/medicaid-chip/providerinformation/medicaid-chip-directed-payment-programs/texas-incentivesphysicians-professional-services-tipps-program
31.Comprehensive Hospital Increased Reimbursement Program (CHIRP) | Texas
Health and Human Services. Accessed January 20, 2022.
https://www.hhs.texas.gov/services/health/medicaid-chip/providerinformation/medicaid-chip-directed-payment-programs/comprehensive-hospitalincreased-reimbursement-program-chirp
32.Directed Payment Program for Behavioral Health Services (DPP BHS) | Texas
Health and Human Services. Accessed January 20, 2022.
https://www.hhs.texas.gov/services/health/medicaid-chip/providerinformation/medicaid-chip-directed-payment-programs/directed-paymentprogram-behavioral-health-services-dpp-bhs
33.Rural Access to Primary and Preventive Services (RAPPS) Program | Texas
Health and Human Services. Accessed January 20, 2022.
https://www.hhs.texas.gov/services/health/medicaid-chip/provider66information/medicaid-chip-directed-payment-programs/rural-access-primarypreventive-services-rapps-program
34.CDC. What is health literacy? Take action. Find out. Centers for Disease Control
and Prevention. Published February 2, 2022. Accessed September 29, 2022.
https://www.cdc.gov/healthliteracy/learn/index.html
35.Adams RJ. Improving health outcomes with better patient understanding andeducation. Risk Manag Healthc Policy. 2010;3:61-72. doi:10.2147/RMHP.S7500
36.Santos P, Sá L, Couto L, Hespanhol A. Health literacy as a key for effective
preventive medicine. Hale R, ed. Cogent Soc Sci. 2017;3(1):1407522.
doi:10.1080/23311886.2017.1407522
37.CDC. The What, Why, and How of Health Literacy. Centers for Disease Control
and Prevention. Published March 29, 2021. Accessed July 7, 2022.
https://www.cdc.gov/healthliteracy/learn/Understanding.html
38.Ranganathan M, Lagarde M. Promoting healthy behaviours and improving healthoutcomes in low and middle income countries: A review of the impact ofconditional cash transfer programmes. Prev Med. 2012;55:S95-S105.
doi:10.1016/j.ypmed.2011.11.015
39.U.S. Department of Commerce, U.S. Census Bureau. American Community
Survey: ACS 5-Year Estimates Data Profiles, 2018: Selected Social
Characteristics In The United States. Accessed March 17, 2022.
https://data.census.gov/cedsci/
40.Leider JP, Meit M, McCullough JM, et al. The State of Rural Public Health:Enduring Needs in a New Decade. Am J Public Health. 2020;110(9):1283-1290.
doi:10.2105/AJPH.2020.305728
41.Hartley D. Rural Health Disparities, Population Health, and Rural Culture. Am J
Public Health. 2004;94(10):1675-1678. doi:10.2105/AJPH.94.10.1675
42.Holmes M. Risk Factors and Potentially Preventable Deaths in Rural
Communities. :4.
43.Johnson JA, Johnson AM. Urban-Rural Differences in Childhood and AdolescentObesity in the United States: A Systematic Review and Meta-Analysis. Child
Obes. 2015;11(3):233-241. doi:10.1089/chi.2014.0085
44.Rural Health Information Hub. Rural Health Disparities Introduction.
https://www.ruralhealthinfo.o rg/topics/rural-health-disparities
45.Curtin SC, Spencer MR. Trends in Death Rates in Urban and Rural Areas: UnitedStates, 1999-2019. NCHS Data Brief. 2021;(417):1-8.
46.Bolin JN, Bellamy GR, Ferdinand AO, et al. Rural Healthy People 2020: New
Decade, Same Challenges. J Rural Health. 2015;31(3):326-333.
doi:https://doi.org/10.1111/jrh.12116

67

47.Texas Department of State Health Services. Office of Border Health. Accessed
February 26, 2021. https://www.dshs.texas.gov/borderhealth/48.Texas Attorney General. Colonias Terms. Accessed February 26, 2021.
https://www.texasattorneygeneral.gov/divisions/colonias-prevention/coloniasterms
49.Mier N, Ory MG, Zhan D, Conkling M, Sharkey JR, Burdine JN. Health-related
quality of life among Mexican Americans living in colonias at the Texas–Mexico
border. Soc Sci Med. 2008;66(8):1760-1771.
doi:10.1016/j.socscimed.2007.12.017
50.Ullrich F, Mueller K. COVID-19 Cases and Deaths, Metropolitan andNonmetropolitan Counties Over Time (update). RUPRI Cent Rural Health Policy
Anal Rural Data Brief. 2022;2020-9. https://rupri.publichealth.uiowa.edu/publications/policybriefs/2020/COVID%20Longitudinal%20Dat
a.pdf
51.Lakhani HV, Pillai SS, Zehra M, Sharma I, Sodhi K. Systematic Review of ClinicalInsights into Novel Coronavirus (CoVID-19) Pandemic: Persisting Challenges in
U.S. Rural Population. Int J Environ Res Public Health. 2020;17(12):E4279.
doi:10.3390/ijerph17124279
52.CDC. Coronavirus Disease 2019 (COVID-19). Centers for Disease Control andPrevention. Published February 11, 2020. Accessed March 30, 2022.
https://www.cdc.gov/coronavirus/2019-ncov/science/science-briefs/underlyingevidence-table.html
53.Sun Y, Monnat SM. Rural-urban and within-rural differences in COVID-19
vaccination rates. J Rural Health Off J Am Rural Health Assoc Natl Rural HealthCare Assoc. Published online September 23, 2021. doi:10.1111/jrh.12625
54.Sociodemographic Determinants of COVID-19 Vaccine Hesitancy, Fear of
Infection, and Protection Self-Efficacy - PMC. Accessed March 29, 2022.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8388227/
55.Texas Department of Agriculture, Texas Rural Health and Economic Advisory
Council. 2018 Rural Policy Plan Report.; 2018.
https://www.texasagriculture.gov/Portals/0/Publications/ER/2018%20Rural%20
Policy%20Plan%20Report.pdf
56.Rural Emergency Medical Services (EMS) and Trauma Overview - Rural Health
Information Hub. Accessed September 29, 2022.
https://www.ruralhealthinfo.org/topics/emergency-medical-services#workforce
57.Texas EMS Alliance. The Issues – 1. Accessed February 26, 2021.
http://txemsa.com/the-issues/
58.87(3) SB 8 - Enrolled version - Bill Text. Accessed September 29, 2022.
https://capitol.texas.gov/tlodocs/873/billtext/html/SB00008F.htm
68

59.Scholarships for EMS Education and Training Available from DSHS. Accessed
September 29, 2022. https://www.dshs.texas.gov/news-alerts/scholarshipsems-education-training-available-dshs/
60.Centers for Medicaid and Medicare Services. President Trump Expands
Telehealth Benefits for Medicare Beneficiaries During COVID-19 Outbreak.
Published May 17, 2020. https://www.cms.gov/newsroom/pressreleases/president-trump-expands-telehealth-benefits-medicare-beneficiariesduring-covid-19-outbreak
61.Office of the Texas Governor. Governor Abbott Waives Regulations, Expands
Telehealth Options. Published April 9, 2020.
https://gov.texas.gov/news/post/governor-abbott-waives-regulations-expandstelehealth-options
62.Texas A&M University Rural and Community Health Institute. What’s Next?
Practical Suggestions for Rural Communities Facing a Hospital Closure.; 2017.
https://architexas.org/news/whats-next-final-rchi.pdf
63.Mulverhill. Texas’ Digital Divide. Texas Comptroller of Public. Accessed February
26, 2021. https://comptroller.texas.gov/economy/fiscalnotes/2019/oct/divide.php
64.Rural Health Research Gateway. Rural Health Research Recap: Rural
Communities: Age, Income, and Health Status.; 2018.
https://www.ruralhealthresearch.org/assets/2200-8536/rural-communities-ageincome-health-status-recap.pdf
65.Texas Demographic Center. 2018 Estimated Population of Texas, Its Counties,
and Places.; 2019.
https://demographics.texas.gov/Resources/publications/2019/20191205_PopEst
imatesBrief.pdf
66.Office of Disease Prevention and Health Promotion. 2020 Topics & Objectives:
Older Adults. healthypeople.gov. https://www.healthypeople.gov/2020/topicsobjectives/topic/older-adults
67.US Census Bureau. Uninsured Rate by State: 2008 to 2018. The United States
Census Bureau. Accessed January 22, 2021.
https://www.census.gov/library/visualizations/interactive/uninsured-rate-20082018.html
68.Khullar D, Chokshi D. Health, Income, & Poverty: Where We Are & What Could
Help, Health Affairs Briefs. Published online October 4, 2018.
doi:10.1377/hpb20180817.901935
69.Texas Organization of Rural and Community Hospitals. Rural Hospital Closures.
torchnet.org. Accessed January 14, 2021. https://www.torchnet.org/advocacy-rural-hospital-closure.html
69

70.Wishner J, Solleveld P, Rudowitz R, Paradise J, Antonisse L. A Look at Rural
Hospital Closures and Implications for Access to Care: Three Case Studies. The
Urban Institute and Kaiser Family Foundation; 2016.
http://www.urban.org/sites/default/files/publication/82511/2000857-brief-alook-at-rural-hospital-closures-and-implications-for-access-to-care.pdf
71.Hsia RYJ, Shen YC. Rising Closures Of Hospital Trauma Centers
Disproportionately Burden Vulnerable Populations. Health Aff (Millwood).
2011;30(10):1912-1920. doi:10.1377/hlthaff.2011.0510
72.Flinn B. Nursing Home Closures and Trends June 2015 - June 2019. Leading
Age. Published February 2020.
https://leadingage.org/sites/default/files/Nursing%20Home%20Closures%20an
d%20Trends%202020.pdf
73.Garfield R, Orgera K, Damico A. The Coverage Gap: Uninsured Poor Adults inStates That Do Not Expand Medicaid. Kaiser Family Foundation; 2020.
https://www.kff.org/medicaid/issue-brief/the-coverage-gap-uninsured-pooradults-in-states-that-do-not-expand-medicaid/
75.Artiga S, Damico A, Garfield R. The Impact of the Coverage Gap for Adults inStates Not Expanding Medicaid by Race and Ethnicity. Kaiser Family Foundation;2015. https://www.kff.org/racial-equity-and-health-policy/issue-brief/theimpact-of-the-coverage-gap-in-states-not-expanding-medicaid-by-race-andethnicity/
76.Lindrooth RC, Perraillon MC, Hardy RY, Tung GJ. Understanding The Relationship
Between Medicaid Expansions And Hospital Closures. Health Aff (Millwood).
2018;37(1):111-120. doi:10.1377/hlthaff.2017.0976
77.Collins C, Novack S. Critical Condition: Part 2: Driving My Life Away. Tex Obs.
Published online November 18, 2019. Accessed January 15, 2021.
https://www.texasobserver.org/driving-my-life-away/
78.Hernandez R. The Rural Health Care Crisis,
Mapped.https://www.texasobserver.org/the-rural-health-care-crisis-mapped/.
Published November 20, 2019. Accessed January 22, 2021.
79.Texas Department of State Health Services. Texas Physician Supply and
Demand Projections, 2018 - 2032.; 2020.
80.Hung P, Kozhimannil KB, Casey MM, Moscovice IS. Why Are Obstetric Units in
Rural Hospitals Closing Their Doors? Health Serv Res. 2016;51(4):1546-1560.
doi:10.1111/1475-6773.12441
81.Kozhimannil KB, Hung P, Henning-Smith C, Casey MM, Prasad S. Association
Between Loss of Hospital-Based Obstetric Services and Birth Outcomes in Rural
Counties in the United States. JAMA. 2018;319(12):1239-1247.
doi:10.1001/jama.2018.1830
70

82.Pennsylvania Rural Health Model. Pennsylvania Department of Health. Accessed
March 30, 2022. https://www.health.pa.gov:443/topics/HealthInnovation/Pages/Rural-Health.aspx
83.A&M Rural and Community Health Institute. Accessed March 29, 2022.
https://www.architexas.org/
84.Health Resources and Services Administration. A Guide for Rural Health Care
Collaboration and Coordination. Published online August 2019.
https://www.hrsa.gov/sites/default/files/hrsa/ruralhealth/reports/HRSA-RuralCollaboration-Guide.pdf
85.U.S. Department of Commerce, U.S. Census Bureau. American Community
Survey: ACS 1-Year Estimates Subject Tables, 2019: Selected Characteristics Of
Health Insurance Coverage In The United States. Accessed March 30, 2022.
https://data.census.gov/cedsci/table?q=United%20States&t=Health%20Insuran
ce&g=0400000US48
86.Families USA, National Center for Coverage Innovation. The COVID-19 Pandemic
and Resulting Economic Crash Have Caused the Greatest Health Insurance
Losses in American History. Accessed March 30, 2022. https://fam
iliesusa.org/wp-content/uploads/2020/07/COV-254_Coverage-Loss_Report_717-20.pdf
87.Hear Us Out Campaign Reports Nurses’ COVID-19 Reality - AACN. Accessed
March 29, 2022. https://www.aacn.org/newsroom/hear-us-out-campaignreports-nurses-covid-19-reality
88.Alrawashdeh HM, Al-Tammemi AB, Alzawahreh MKh, et al. Occupational burnout
and job satisfaction among physicians in times of COVID-19 crisis: a convergent
parallel mixed-method study. BMC Public Health. 2021;21(1):811.
doi:10.1186/s12889-021-10897-4
89.Bureau of Labor Statistics. The Employment Situation - February 2022.
Published online March 2022. https://www.bls.gov/news.release/pdf/empsit.pdf
90.Rural Texans hit hardest as state sees shortage of primary care doctors during
the pandemic. KUT Radio, Austin’s NPR Station. Published November 18, 2021.
Accessed July 7, 2022. https://www.kut.org/health/2021-11-18/rural-texanshit-hardest-as-state-sees-shortage-of-primary-care-doctors-during-thepandemic
91.‘Nursing Is in Crisis’: Staff Shortages Put Patients at Risk. N Y Times. Published
online August 21, 2021.
https://www.pnns.org/resources/Documents/Jacobs%20NYT%20August%20202
1%20_Nursing%20Is%20in%20Crisis%E2%80%99_%20Staff%20Shortages%2
0Put%20Patients%20at%20Risk%20-%20The%20New%20York%20Times.pdf

7192.Texas Higher Education Coordinating Board. Types of Financial Aid - Loan
Repayment Programs. Accessed March 30, 2022.
http://www.hhloans.com/apps/financialaid/tofa.cfm?Kind=LRP
93.Report on Residents. AAMC. Accessed March 29, 2022.
https://www.aamc.org/data-reports/students-residents/report/report-residents
94.Health Resources and Services Administration. 2016 NHSC Participant
Satisfaction Survey Results. Published online January 2017.
https://www.hrsa.gov/sites/default/files/hrsa/advisory-committees/nationalhealth-service-corps/advisory-council-meeting-January-2017-nhsc-participantsurvey-results.pdf
95.Lam O, Broderick B, Toor S. How far Americans live from the closest hospitaldiffers by community type. Pew Research Center. Accessed March 24, 2022.
https://www.pewresearch.org/fact-tank/2018/12/12/how-far-americans-livefrom-the-closest-hospital-differs-by-community-type/96.The Caring Foundation of Texas. Care Van. Caring Foundation of Texas.
Accessed March 30, 2022. https://carevan.org/
97.Texas Broadband Development Office. Accessed April 26, 2022.
https://comptroller.texas.gov/programs/broadband/legislation.php
98.Walker JH, Dewitt DE, Pallant JF, Cunningham CE. Rural origin plus a rural
clinical school placement is a significant predictor of medical students’ intentions
to practice rurally: a multi-university study. Rural Remote Health.
2012;12:1908.
99.Health Professions Recruitment and Exposure Program (HPREP): Non-degree
Programs - UT Southwestern, Dallas, TX. Accessed April 4, 2022.
https://www.utsouthwestern.edu/education/programs/nondegreeprograms/high-school-students/hprep/
100. Texas Center for Nursing Workforce Studies. 2021 Nursing Education for HighSchool Students. Published online March 2022.
https://dshs.texas.gov/chs/cnws/NEPIS/2021/2021_NEPIS_HighSchool.pdf
101. Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, Walters EE. Lifetime
Prevalence and Age-of-Onset Distributions of DSM-IV Disorders in the National
Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62(6):593-602.
doi:10.1001/archpsyc.62.6.593
102. The Hogg Foundation for Mental Health and Methodist Healthcare Ministries.
Crisis Point: Mental Health Workforce Shortages in Texas. Accessed May 4,2022. https://www.mhm.org/library/policy-publications/crisis-point-mentalhealth-workforce-shortages-in-texas/
103. National Research Council (US) and Institute of Medicine (US) Committee on
the Prevention of Mental Disorders and Substance Abuse Among Children,72Youth, and Young Adults: Research Advances and Promising Interventions.
Preventing Mental, Emotional, and Behavioral Disorders Among Young People:
Progress and Possibilities. (O’Connell ME, Boat T, Warner KE, eds.). National
Academies Press (US); 2009. Accessed May 4, 2022.
http://www.ncbi.nlm.nih.gov/books/NBK32775/
104. U.S Department of Health and Human Services, Substance Abuse and Mental
Health Services Administration, Center for Behavioral Health Statistics andQuality, Populations Survey Branch. Key Substance Use and Mental HealthIndicators in the United States: Results from the 2020 National Survey on Drug
Use and Health. Published online 2020:156.
105. Cunningham PJ. Beyond Parity: Primary Care Physicians’ Perspectives On
Access To Mental Health Care. Health Aff (Millwood). 2009;28(Supplement1):w490-w501. doi:10.1377/hlthaff.28.3.w490
106. Burea of Health Workforce, Health Resources and Services Administration(HRSA), U.S. Department of Health & Human Services. Designated HealthProfessional Shortage Areas Statistics: Second Quarter of Fiscal Year 2022.
Published online March 31, 2022.
https://data.hrsa.gov/Default/GenerateHPSAQuarterlyReport107. American Psychological Association. Psychology and aging: Addressing
mental health needs of older adults: (526182009-001). Published online 2009.
doi:10.1037/e526182009-001
108. Hoge MA, Stuart GW, Morris J, Flaherty MT, Paris M, Goplerud E. Mental
Health And Addiction Workforce Development: Federal Leadership Is Needed To
Address The Growing Crisis. Health Aff (Millwood). 2013;32(11):2005-2012.
doi:10.1377/hlthaff.2013.0541
109. U.S. Department of Health and Human Services, Health Resources andServices Administration, National Center for Health Workforce Analysis.
Behavioral Health Workforce Projections: Addiction Counselors. Accessed May 4,2022. https://bhw.hrsa.gov/data-research/projecting-health-workforce-supplydemand/behavioral-health110. Thomas KC, Ellis AR, Konrad TR, Holzer CE, Morrissey JP. County-Level
Estimates of Mental Health Professional Shortage in the United States. Psychiatr
Serv. 2009;60(10):1323-1328. doi:10.1176/ps.2009.60.10.1323
111. Texas Health and Human Services Commission, Behavioral Health Services
Section, Office of Decision Support. Data Provided August 8, 2018.
112. Texas Department of State Health Services. Youth Risk Behavior Survey(YRBS), 2019. Accessed May 4, 2022.
https://healthdata.dshs.texas.gov/dashboard/surveys-and-profiles/yrbs

73

113. Tomblin Murphy G, Birch S, MacKenzie A, Alder R, Lethbridge L, Little L.
Eliminating the shortage of registered nurses in Canada: An exercise in applied
needs-based planning. Health Policy. 2012;105(2):192-202.
doi:10.1016/j.healthpol.2011.11.009
114. Texas Department of State Health Services, Texas Primary Care Office. Data
Provided June 16, 2020.
115. Thomas KC, Ellis AR, Konrad TR, Morrissey JP. North Carolina’s mental healthworkforce: unmet need, maldistribution, and no quick fixes. N C Med J.
2012;73(3):161-168.
116. Texas Department of State Health Services, Texas Health & Human Services.
Texas Physician Supply and Demand Projections, 2018 - 2032. Published online
May 2020. https://dshs.texas.gov/legislative/2020Reports/TexasPhysicianSupplyDemandProjections-2018-2032.pdf
117. Texas Health Professions Resource Center Mental Health Professions 2021
Data.
118. American School Counselor Association. Student-to-School-Counselor Ratio
2020–2021. https://www.schoolcounselor.org/getmedia/238f136e-ec52-4bf294b6-f24c39447022/Ratios-20-21-Alpha.pdf
119. National Association of School Psychologists. NASP Policy Platform. National
Association of School Psychologists (NASP). Accessed May 4, 2022.
https://www.nasponline.org/research-and-policy/policy-priorities/nasp-policyplatform
120. Texas Education Agency, PEIMS Reporting Unit, Research and Analysis
Division. Staff FTE Counts and Salary Reports. Accessed May 4, 2022.
https://rptsvr1.tea.texas.gov/adhocrpt/adpeb.html
121. Texas Education Agency, Office of Governance and Accountability, Division of
Research and Analysis. Enrollment in Texas Public Schools 2020-21. Published
online 2021:86.
122. The Mayo Clinic Health System. College Students and Depression. Mayo
Clinic Health System. Accessed June 27, 2022.
https://www.mayoclinichealthsystem.org/hometown-health/speaking-ofhealth/college-students-and-depression
123. Son C, Hegde S, Smith A, Wang X, Sasangohar F. Effects of COVID-19 on
College Students’ Mental Health in the United States: Interview Survey Study. J
Med Internet Res. 2020;22(9):e21279. doi:10.2196/21279
124. Centers for Disease Control and Prevention. Youth Online: High School YRBS
- Texas 2019 Results. Accessed May 4, 2022.
https://nccd.cdc.gov/youthonline/app/Results.aspx?TT=A&OUT=0&SID=HS&QI
D=QQ&LID=TX&YID=2019&LID2=&YID2=&COL=S&ROW1=N&ROW2=N&HT=Q
74

Q&LCT=LL&FS=S1&FR=R1&FG=G1&FA=A1&FI=I1&FP=P1&FSL=S1&FRL=R1&F
GL=G1&FAL=A1&FIL=I1&FPL=P1&PV=&TST=False&C1=&C2=&QP=G&DP=1&VA=CI&CS=Y&SYID=&EYID=&SC=DEFAULT&SO=ASC
125. Texas Legislature Online. 86(R) History for SB 11. Accessed May 4, 2022.
https://capitol.texas.gov/BillLookup/History.aspx?LegSess=86R&Bill=SB11
126. Texas Health and Safety Code, Section 113.0052. Accessed May 4, 2022.
https://statutes.capitol.texas.gov/Docs/HS/htm/HS.113.htm
127. The University of Texas System. TCMHCC – Texas Child Mental Health Care
Consortium. Accessed May 4, 2022. https://tcmhcc.utsystem.edu/
128. Texas Health and Safety Code, Section 113.0101. Accessed May 4, 2022.
https://statutes.capitol.texas.gov/Docs/HS/htm/HS.113.htm
129. Texas Health and Safety Code, Section 113.0051. Accessed May 4, 2022.
https://statutes.capitol.texas.gov/Docs/HS/htm/HS.113.htm
130. Texas Health and Safety Code, Sections 113.0201 and 113.0202. Accessed
May 4, 2022. https://statutes.capitol.texas.gov/Docs/HS/htm/HS.113.htm
131. Texas Legislature Online. 87(R) History for SB 1. Accessed May 4, 2022.
https://capitol.texas.gov/billlookup/History.aspx?LegSess=87R&Bill=SB1132. General Appropriations Act for the 2016-17 Biennium, Eighty-fourth Texas
Legislature, Regular Session, 2015.
https://capitol.texas.gov/tlodocs/87R/billtext/pdf/SB00001F.pdf
133. Texas Government Code, Section 531.472.
https://statutes.capitol.texas.gov/Docs/GV/htm/GV.531.htm
134. 87(R) HB 4074 - Senate Committee Report version - Bill Text. Accessed May
4, 2022. https://capitol.texas.gov/tlodocs/87R/billtext/html/HB04074S.htm
135. Texas Statewide Behavioral Health Coordinating Council. Texas Statewide
Behavioral Health Strategic Plan, Fiscal Years 2017-2021.; 2016.
http://mmhpi.org/wp-content/uploads/2018/07/Statewide-Behavioral-HealthStrategic-Plan.pdf
136. Texas Administrative Code, Title 19, Part 1, Chapter 23, Subchapter D.
https://texreg.sos.state.tx.us/public/readtac$ext.ViewTAC?tac_view=5&ti=19&p
t=1&ch=23&sch=D&rl=Y
137. Texas Administrative Code, Title 19, Part 1, Chapter 23, Subchapter D, Rule§23.95.
https://texreg.sos.state.tx.us/public/readtac$ext.TacPage?sl=R&app=9&p_dir=&p_rloc=&p_tloc=&p_ploc=&pg=1&p_tac=&ti=19&pt=1&ch=23&rl=95
138. Texas Administrative Code, Title 19, Part 1, Chapter 23, Subchapter D, Rule§23.96.
https://texreg.sos.state.tx.us/public/readtac$ext.TacPage?sl=R&app=9&p_dir=&p_rloc=&p_tloc=&p_ploc=&pg=1&p_tac=&ti=19&pt=1&ch=23&rl=9675

139. St. John Fisher College. Federal Grant Expands Mental Health Program.
Published 2021. Accessed May 4, 2022. https://www.sjfc.edu/news-andevents/news-archive/fall-2021/federal-grant-expands-mental-health-program/
140. Center for Disease Control and Prevention. Mental Health - Household Pulse
Survey - COVID-19. Published April 20, 2022. Accessed May 4, 2022.
https://www.cdc.gov/nchs/covid19/pulse/mental-health.htm
141. Texas Department of State Health Services. HHSC Launches $23.2 Million
Substance Use Prevention Awareness Campaign Effort | Texas Health andHuman Services. Accessed May 4, 2022.
https://www.hhs.texas.gov/news/2022/03/hhsc-launches-23-2-millionsubstance-use-prevention-awareness-campaign-effort
142. Centers for Disease Control and Prevention, National Center for Health
Statistics. Provisional Drug Overdose Data. Published April 5, 2022. Accessed
May 4, 2022. https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm
143. Texas Health and Human Services. COVID-19 Mental Health Support Line
Helps Thousands of Texans. Accessed May 4, 2022.
https://www.hhs.texas.gov/news/2021/09/covid-19-mental-health-support-linehelps-thousands-texans
144. Statewide Behavioral Health Coordinating Council. Strong Families,
Supportive Communities: Moving Our Behavioral Health Workforce Forward.;
2020. Accessed May 4, 2020.
https://www.hhs.texas.gov/sites/default/files/documents/lawsregulations/reports-presentations/2020/behavioral-health-workforce-workgroupreport-dec-2020.pdf
145. Health Resources & Services Administration. Shortage Areas. Accessed May
16, 2022. https://data.hrsa.gov/topics/health-workforce/shortage-areas
146. Texas Health and Human Services. Texas HHS Receives National Suicide
Prevention Lifeline Grant | Texas Health and Human Services. Published 2021.
Accessed May 4, 2022. https://www.hhs.texas.gov/news/2021/02/texas-hhsreceives-national-suicide-prevention-lifeline-grant147. Telemedicine | Medicaid. Medicaid.gov. Accessed February 22, 2022.
https://www.medicaid.gov/medicaid/benefits/telemedicine/index.html
148. OCCUPATIONS CODE CHAPTER 111. TELEMEDICINE, TELEDENTISTRY, AND
TELEHEALTH. Accessed February 22, 2022.
https://statutes.capitol.texas.gov/Docs/OC/htm/OC.111.htm
149. Achenbach SJ. Telemedicine: Benefits, Challenges, and its Great Potential.
Health Law Policy Brief. 2020;14(1):26.
150. 2000, Program Authorization, Services and Definitions. Accessed February
22, 2022. https://www.hhs.texas.gov/book/export/html/266896
76151. Texas Health and Human Services. Telemedicine, Telehealth, and Home
Telemonitoring Services in Texas Medicaid. Accessed November 17, 2021.
https://www.hhs.texas.gov/sites/default/files/documents/lawsregulations/reports-presentations/2020/sb-789-telemedicine-telehealth-htsmedicaid-dec-2020.pdf
152. E-Health Advisory Committee | Texas Health and Human Services. Accessed
October 27, 2021. https://www.hhs.texas.gov/about/leadership/advisorycommittees/e-health-advisory-committee
153. Public Health Emergency. U.S. Department of Health & Human Services.
Accessed October 27, 2021.
https://www.phe.gov/emergency/news/healthactions/phe/Pages/default.aspx
154. Governor Abbott Waives Certain Regulations For Telemedicine Care In
Texas.https://gov.texas.gov/news/post/governor-abbott-waives-certainregulations-for-telemedicine-care-in-texas. Published March 17, 2020. Accessed
November 17, 2021.
155. Governor Abbott Announces Agreement With Health Insurers To Continue
Payment Parity For Telehealth. Published September 25, 2020. Accessed
November 17, 2021. https://gov.texas.gov/news/post/governor-abbottannounces-agreement-with-health-insurers-to-continue-payment-parity-fortelehealth156. Texas HB4 | 2021-2022 | 87th Legislature. LegiScan. Accessed November
22, 2021. https://legiscan.com/TX/text/HB4/id/2407389
157. Texas SB228 | 2021-2022 | 87th Legislature. LegiScan. Accessed November
17, 2021. https://legiscan.com/TX/text/SB228/id/2218519
158. Texas SB434 | 2021-2022 | 87th Legislature. LegiScan. Accessed November
17, 2021. https://legiscan.com/TX/bill/SB434/2021
159. Texas SB488 | 2021-2022 | 87th Legislature. LegiScan. Accessed January
16, 2021. https://legiscan.com/TX/drafts/SB488/2021
160. Texas Health and Human Services. Assessment of Texas Medicaid Rural
Teleservices.; :96. Accessed November 17, 2021.
https://www.hhs.texas.gov/sites/default/files/documents/lawsregulations/policies-rules/Waivers/medicaid-1115-waiver/assessment-texasmedicaid-rural-teleservices.pdf
161. Texas Medicaid & CHIP Teleservices Monthly Trend | Texas Health andHuman Services. Accessed January 12, 2022.
https://www.hhs.texas.gov/data/texas-medicaid-chip-teleservices-monthlytrend77162. Mosquera RA, Avritscher EBC, Pedroza C, et al. Telemedicine for Children
With Medical Complexity: A Randomized Clinical Trial. Pediatrics.
2021;148(3):e2021050400. doi:10.1542/peds.2021-050400
163. Ramirez AV, Ojeaga M, Espinoza V, Hensler B, Honrubia V. Telemedicine in
Minority and Socioeconomically Disadvantaged Communities Amidst COVID-19
Pandemic. Otolaryngol Neck Surg. 2021;164(1):91-92.
doi:10.1177/0194599820947667
164. Texas Launches Broadband Office to Guide Expansion. GovTech. Published
August 6, 2021. Accessed November 3, 2021.
https://www.govtech.com/civic/texas-launches-broadband-office-to-guideexpansion
165. Texas Legislature Online - 87(3) History for HB 76. Accessed November 3,2021.
https://capitol.texas.gov/BillLookup/History.aspx?LegSess=873&Bill=HB76
166. mHealthIntelligence. Texas Lawmaker Eyes Telehealth Program for Rural 911
Services. mHealthIntelligence. Published October 13, 2021. Accessed November
3, 2021. https://mhealthintelligence.com/news/texas-lawmaker-eyestelehealth-program-for-rural-911-services
167. Telemedicine Policy, Regulations, and Reimbursement in Texas. Accessed
November 3, 2022. https://www.texmed.org/telemedicine/168. Physician License. Interstate Medical Licensure Compact. Accessed December
10, 2022. https://www.imlcc.org/
169. Weiner S. What happens to telemedicine after COVID-19? AAMC.
https://www.aamc.org/news-insights/what-happens-telemedicine-after-covid19. Published October 21, 2021. Accessed November 11, 2021.
170. Medicaid and CHIP Teleservices | Texas Health and Human Services.
Accessed December 15, 2021.
https://www.hhs.texas.gov/services/health/medicaid-chip/providerinformation/medicaid-chip-teleservices
171. HIE Benefits | HealthIT.gov. The Office of the National Coordinator for Health
Information Technology (ONC). Published October 12, 2017. Accessed April 6,
2022. https://www.healthit.gov/topic/health-it-and-health-informationexchange-basics/hie-benefits
172. HITECH Act Enforcement Interim Final Rule. HHS.gov. Published October 28,
2009. Accessed April 6, 2022. https://www.hhs.gov/hipaa/forprofessionals/special-topics/hitech-act-enforcement-interim-final-rule/index.html
173. Statewide Health Information Exchange | Texas Health and Human Services.
Texas Health and Human Services. Accessed April 6, 2022.
https://www.hhs.texas.gov/about/process-improvement/improving-services78

texans/health-informatics-services-quality/statewide-health-informationexchange
174. Nachum S, Gogia K, Clark S, Hsu H, Sharma R, Greenwald PW. An Evaluationof Kiosks for Direct-to-Consumer Telemedicine Using the National Quality Forum
Assessment Framework. Telemed E-Health. 2021;27(2):178-183.
doi:10.1089/tmj.2019.0318

79